Journal of evaluation in clinical practice
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Inappropriate use of telemetry frequently occurs in the inpatient, non-intensive care unit setting. Telemetry practice standards have attempted to guide appropriate use and limit the overuse of this important resource with limited success. Clinical-effectiveness studies have thus far not included care settings in which resident-physicians are the primary caregivers. ⋯ These findings expand our understanding of telemetry use in the academic care setting in which trainees serve as the primary caregivers. Furthermore, these findings represent an important addition to the telemetry and patient monitoring literature by demonstrating the impact that nurse-managed protocols can have on telemetry use and by highlighting effective strategies to improve telemetry use by physicians in training.
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Review
Improving quality in a complex primary care system-An example of refugee care and literature review.
Applying traditional industrial quality improvement (QI) methodologies to primary care is often inappropriate because primary care and its relationship to the healthcare macrosystem has many features of a complex adaptive system (CAS) that is particularly responsive to bottom-up rather than top-down management approaches. We report on a demonstration case study of improvements made in the Family Health Center (FHC) of the JPS Health Network in a refugee patient population that illustrate features of QI in a CAS framework as opposed to a traditional QI approach. ⋯ Meaningful improvement in primary care is more likely achieved when the impetus to implement change shifts from top-down to bottom-up.
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Meta Analysis
Methodological assessment of systematic reviews and meta-analyses on COVID-19: A meta-epidemiological study.
COVID-19 has caused an ongoing public health crisis. Many systematic reviews and meta-analyses have been performed to synthesize evidence for better understanding this new disease. However, some concerns have been raised about rapid COVID-19 research. This meta-epidemiological study aims to methodologically assess the current systematic reviews and meta-analyses on COVID-19. ⋯ The current systematic reviews and meta-analyses on COVID-19 might suffer from low transparency, high heterogeneity, and suboptimal statistical methods. It is recommended that future systematic reviews on COVID-19 strictly follow well-developed guidelines. Sensitivity analyses may be performed to examine how the synthesized evidence might depend on different methods for appraising evidence, assessing publication bias, and implementing meta-analysis models.
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Uncertainty is a complex and constant phenomenon in clinical practice. How medical students recognize and respond to uncertainty impacts on their well-being, career choices, and attitudes towards patients. It has been suggested that curricula should do more to prepare medical students for an uncertain world. In order to teach medical students about uncertainty, we need to understand how uncertainty has been conceptualized in the literature to date. The aim of this article is to explore existing models of uncertainty and to develop a framework of clinical uncertainty to aid medical education. ⋯ The developed framework of clinical uncertainty highlights sources, subjective influencers, responses to uncertainty, and the dynamic relationship among these elements. Our framework illustrates the different aspects of knowledge as a source of uncertainty and how to distinguish between those aspects. Our framework highlights the complexity of sources of uncertainty, especially when including uncertainty arising from relationships and systems. These sources can occur in combination. Our framework is also novel in how it describes the impact of influencers such as personal characteristics, experience, and affect on perceptions of and responses to uncertainty. This framework can be used by educators and curricula developers to help understand and teach about clinical uncertainty.