Special report. Patients in possession of illegal drugs: what can you do about it?

Illicit drug use affects every area of the hospital/health care setting and presents thorny legal dilemmas for security directors and risk managers when patients are found using and/or attempting to sell controlled substances. Should you handle it privately or should you call in the police? Do local law enforcement and prosecutors really want to be bothered with every $25 worth of cocaine seized from a patient? If you inform the police and arrests are made, could your hospital develop a reputation as a drug-infested combat zone? If you handle it privately, are you at risk for litigation because of invasion of privacy or an illegal search? On the other hand, if drugs are reported and you do nothing, are you liable for a negligence lawsuit? Clearly, there is a need for proactive planning and policy development prior to being confronted with patient drug possession. In this report, hospital security directors discuss how they handle this situation at their facilities and how they formulate policies and procedures. We'll also offer advice from legal experts on patient privacy issues and interacting with local law enforcement.     

Radiation dose in computed tomography: why it's a concern and what you can do about it

Computed tomography (CT) has become an invaluable and even life-saving diagnostic tool. But its great benefits come at a price: Because it uses ionizing radiation, CT can cause cancer. In fact, in the United States alone, it is estimated that CT accounts for around 6,000 additional cancers per year, with about half of those proving fatal. Unfortunately, this risk is not as widely recognized as it should be. In particular, both clinicians and patients tend to lack a clear understanding of the radiation doses involved in CT studies, which are higher than those used in other common x-ray studies. Given the swiftly growing use of CT, there's the real possibility that patients' exposure to radiation will grow as well. Thus, it's vital that clinicians understand the doses involved in CT, that those doses be kept as low as possible, and that CT be used only when the clinical benefits justify it. In this article, we explain the radiation risks of CT and discuss how they compare with other risks in and out of healthcare. We also discuss ways in which the doses delivered to patients can be kept to the necessary minimum. The approaches we cover include eliminating unnecessary CT use, raising referring physicians' awareness of the problem, considering alternative technologies, using good quality assurance, and optimizing imaging protocols.     

It's not just what you say,it's also how you say it: Opening the ‘black box’ of informed consent appointments in randomised controlled trials

Randomised controlled trials (RCTs) represent the gold standard methodology for determining effectiveness of healthcare interventions. Poor recruitment to RCTs can threaten external validity and waste resources. An inherent tension exists between safeguarding informed decision-making by participants and maximising numbers enrolled. This study investigated what occurs during informed consent appointments in an ongoing multi-centre RCT in the UK. Objectives were to investigate: 1] how study staff presented study information to participants; 2] what evidence emerged as to how well-informed participants were when proceeding to randomisation or treatment selection; and 3] what aspects of the communication process may facilitate improvements in providing evidence of informed consent. Qualitative analysis of a purposive sample of 23 recruitment appointments from three study centres and involving several recruitment staff applied techniques of thematic, content and conversation analysis (CA). Thematic analysis and CA revealed variation in appointment content and structure. Appointments were mostly recruiter-led or participant-led, and this structure was associated with what evidence emerged as to how participants understood information provided and whether they were in equipoise. Participant-led appointments provided this evidence more consistently. Detailed CA identified communication techniques which, when employed by recruiters, provided evidence as to how participants understood the choices before them. Strategic use of open questions, pauses and ceding the floor in the interaction facilitated detailed and systematic exploration of each participant's concerns and position regarding equipoise. We conclude that the current focus on content to be provided to achieve informed consent should be broadened to encompass consideration of how information is best conveyed to potential participants. A model of tailored information provision using the communication techniques identified and centred on eliciting and addressing participants' concerns is proposed. Use of these techniques is necessary to make potential participants' understanding of key issues and their position regarding equipoise explicit in order to facilitate truly informed consent.     

'Even if they ask you to stand by a tree all day, you will have to do it (laughter)...!': community voices on the notion and practice of informed consent for biomedical research in developing countries

Ethical dilemmas in biomedical research, especially in vulnerable populations, often spark heated debate. Despite recommendations and guidelines, many issues remain controversial, including the relevance, prioritisation and application of individual voluntary informed consent in non-Western settings. The voices of the people likely to be the subjects of research have been notably absent from the debate. We held discussions with groups of community members living in the rural study area of a large research unit in Kenya. Discussions were facilitated by three research study vignettes outlining one field-based and two hospital-based studies being planned or taking place at the time. In addition to gathering general views about the aims and activities of the research unit, questions focused on whether consent should be sought for studies, and if so from whom (chiefs, elders, men/women, children), and on ascertaining whether there are any special concerns about the physical act of signing consent forms. The findings revealed the community's difficulty in distinguishing research from clinical investigations conducted in clinical settings. There was a spectrum of views regarding perceived appropriateness of consent procedures, in part because of difficulty in disentangling clinical from research aims, and because of other challenges to applying consent in practice. Debates between community members highlight the inadequacy of simplistic assumptions about community members' views on informed consent, and the complexity of incorporating lay opinions into biomedical research. Failure to appreciate these issues risks exaggerating differences between settings, and underestimating the time and resources required to ensure meaningful community involvement in research processes. Ultimately, it risks inadequately responding to the needs and values of those on whom the success of most biomedical research depends. Although compliance with community views does not necessarily make the research more ethical, it is argued that community opinions on local issues and practices should inform ethical decision-making in health research.     

Compensation of hospital security directors: how does it compare with other industries and with other managers in the healthcare industry? What can you do to earn more?

A number of studies have been published recently which enable hospital security directors to evaluate where they currently stand compensation-wise and what their potential might be. These studies also enable them to compare salary levels with those of their counterparts in other industries and with those of other middle managers in their own field. In this report, we'll review some of the findings and what we believe they imply. We'll also present our recommendations on what can be done, if anything, to achieve salary levels more commensurate with the levels of responsibility held by security directors in the three fields that provide public accommodations--health care, higher education, and lodging.     

'I just saw it as something that would pull you down, rather than lift you up': resilience in never-smokers with mental illness

Why people smoke despite the health risks is an important public health question. Equally important is why and how some people resist smoking in spite of circumstances that clearly place them at high risk of becoming smokers. This study used in-depth interviews to explore the narratives of 12 people diagnosed with mental illness, who had made conscious decisions not to smoke. This was despite most of them growing up in smoking families or being from population groups at high risk of smoking. A qualitative grounded theory methodology was used to analyse common themes around protective behaviours and attitudes within a model of resilience. Themes included strong negative reactions to smoking as children which have persisted into adulthood, strong lasting associations with smoking, a clear sense of 'self' separate from peers from an early age (internal resilience) and developing a range of coping strategies and external supports not related to smoking (external resilience). Understanding resilience holds potential lessons for health promotion and primary health care professionals supporting the prevention of smoking uptake and supporting smoking cessation by at risk groups.     

Third-party informed consent in research with adolescents: the good, the bad and the ugly

Third-party informed consent for child and adolescent participation in research is a legal requirement that has been questioned by authors who argue that children over 10 are fully able to make decisions regarding this matter. The extent to which this requirement encumbers survey researches in this age range has not been fully reported. In order to understand the reasons for the inconsistent use of condoms among adolescent students in Rio de Janeiro, we designed a survey based on an anonymous self-reported questionnaire. Two informed consent terms were distributed: one for the adolescent and one for the legal representative signature. Participation was offered to all students aged 12-18 attending class at the day of the consent term distribution. Among 906 distributed legal represents consent terms, 734 (81%) were not returned. The final sample probably presented a bias of selection. Researchers must foresee third-party consent as a major encumbrance. There is a need for the definition of a range of interventions in which the adolescent might have the legal recognition of autonomy for decision about his/her voluntary participation.     

It's not just what you do, it's the way that you do it: the effect of different payment card formats and survey administration on willingness to pay for health gain

A general population sample of 314 Australian respondents were randomly allocated to complete a contingent valuation survey administered by face-to-face or telephone ('phone-mail-phone') interview. Although the telephone interview was quicker to complete, no significant difference was found in values obtained through either method. Within each sub-sample, respondents were also randomly allocated to the three different versions of the payment card (PC) questionnaire format: values listed from high-to-low, values listed from low-to-high and values randomly shuffled. The high-to-low version resulted in significantly higher values than the other versions. Further analyses indicate that the randomly shuffled PC version may produce the most 'valid' values.     

What you do not know about disease management: a new ally in the pay-for-performance era

Disease management is relatively new, and many medical practices have misconceptions about how it works. Far from being a burden to busy medical practices, disease management programs can reduce hassles for physicians and office managers by coaching patients to be more compliant, better prepared, and less likely to make unnecessary phone calls. Disease management programs cost the medical practices nothing. They can even help practices make money by providing data needed for bonuses from the growing number of pay-for-performance programs.