collapsology

Sourish Has picked this paper, in Worthing Emergency Medicine we all have to be collapsologists so I think this is a good choice. Here follows a short summary of paper 

Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis

Type of study

A meta-analysis and systematic review 

Objective ;To assess effective of multifactoral assessment and intervention to prevent falls in a variety of settings. 

Studies; 19 Randomised non-blinded trials undertaken in the UK and elsewhere. Mostly home based interventions but some based in Emergency departments. Interventions included supervised exercise, drug review and knowledge(not quite sure what this entailed)

Results; A small non-statistically significant difference in reduction of falls and fall related injuries. 

Author's conclusion; Limited evidence this type of intervention is beneficial

 

Internal validity- Positives

Flow diagram of selection procedure 

2 independent reviewers

Good duration of follow- up- generally 12 months plus

Clearly focused question

 

Interval Validity- Negatives

Inclusion of quasi-randomized trials, some questionable randomisations in the RCT. 

Non-blinded interventions- increased chance of false positives 

Significant heterogeneity  

No funnel plot - nice diagram to demonstrate publication bias but less relevant in negative trial

 

External Validity-  Positives

Mostly U.K based studies

Includes Emergency department-based interventions

 

External Validity-Negatives

Largely home based interventions (lack of applicability to ED setting)

Is a preventative treatment - less relevant to a/e

 

My conclusion

Overall, despite the slight drawbacks of the studies included- this is still the best available evidence to date and would make me hesitant about putting in place a preventive system in the Emergency department, good news for those who favor keeping the ED a treatment only area..

The good news is we will still have many patients falling over and keeping us in a job and further supports the moving of frailty treatment approaches to the front door. 

 

A discussion on rudeness

A great turn out for our inaugural journal club! All grades and backgrounds which is why it was good to talk about a broad topic. 

There was some constitutional about the definition of rudeness and concerns about the external validty of a Israeli NICU simulation study to the emergency department. 

It was good to have nursing colleges on board who were surprised how the medical staff were very much used to rudeness from our seniors throughout our training. Several solutions were brainstorm regarding improving the rudeness of our colleges in other departments but not sure how practical some of these were. 

Our clinical librarian linked me to few more articles on the topic. These particularity echoed what we instructively thought, that this was learnt behavior and not just ingrained personality. A follow up paper suggested "When disrespectful behavior occurs, it must be addressed consistently and transparently. Central to an effective response is a code of conduct that establishes unequivocally the expectation that everyone is entitled to be treated with courtesy, honesty, respect, and dignity." Which makes sense

Interestingly a qualitative paper mirrored what we were saying that this problem affect juniors more and came from specific specialties.

However, formal literature is all well and good, but I think everyone agreed Worhting Emergency department was a particular un-rude place to work. Hopefully that benefits our patients as well as our staff

 

The Impact of Rudeness on Medical Team Performance: A Randomized Trial

To be discussed 21st Feburary 

Objective

To explore the impact of rudeness on the performance of A NICU team.

Design

A simulation-based randomised controlled trial

Setting

A simulated NICU environment

Population

72 NICU professional (nurses and doctors) organised into 3 person teams

Methods

Part pants randomly assigned to a time of day due to shift patterns then stratified randomised to either rudeness or control

Intervention

An outside party commented poorly who their general characteristics but not on performance before hand and at 10 minutes

Control

Interruptions that were neutral in tone

Outcome

Performance rating 1-5 by independent observers (diagnostic performance, procedural performance, information-sharing and help seeking)

Results

The composite diagnostic and procedural performance scores were lower for members of teams exposed to rudeness than to members of the control teams (2.6 vs 3.2 [P = .005] and 2.8 vs 3.3 [P = .008],

Authors conclusion

Rudeness has adverse outcomes on diagnostic and procedural performance in a NICU team.

 

 

Internal Validty -Pros

Large sample size

Matched for experience and other factors

Intervention couldn’t have only had indirect effect, therefore isolated rudeness quite well

Clever design to ensure double blinding

Randomised

 

 

Internal Validty- Cons

Multiple outcomes- not clear which is primary outcome

No power calculation documented

Script of rudeness includes references to poor Israeli medical performance- ?co-founding factor in performance

Less direct outcome, ?if more significant errors made

 

 

 

External validty- Pros

Rudeness was very non-specific and could be applied to any situation.

Stressful clinical critical care scenario with small team applicable

 

External validty -Cons

Israeli study- rudeness largely insulting Israel! -? Applicability to U.K setting

Simulation based study

Not an A/E study (are we thicker skinned than paediatric intensivists?)

 

In conclusion I think this study is a very well conducted and gives a surprisingly profound effect (half a point differences on a 1-5 scale) considering fairly benign rudeness in the intervention. Highlights the need to be as polite and positive as possible.

 

Dan

Starting a journal club in the 21st century

Part of my job as an enthusiastic fellow is to integrate my more experienced colleges knowledge into a more modern context. 

In light of this our new journal club in Worthing will be open to both traditional journals but newer FOAM content as well. 

In light of this will encourage presents to summarise and comment on whatever they wish to bring to the table before the club so everyone can get a handle on what the jist is before we discuss it in person. 

As always, any comments on suggestions welcome. 

 

Dan