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1.  Quantifying the demand for hospital care services: a time and motion study 
Background
The actual amount of care hospitalised patients need is unclear. A model to quantify the demand for hospital care services among various clinical specialties would avail healthcare professionals and managers to anticipate the demand and costs for clinical care.
Methods
Three medical specialties in a Dutch university hospital participated in this prospective time and motion study. To include a representative sample of patients admitted to clinical wards, the most common admission diagnoses were selected from the most recent update of the national medical registry (LMR) of ICD-10 admission diagnoses. The investigators recorded the time spent by physicians and nurses on patient care. Also the costs involved in medical and nursing care, (surgical) interventions, and diagnostic procedures as an estimate of the demand for hospital care services per hospitalised patient were calculated and cumulated. Linear regression analysis was applied to determine significant factors including patient and healthcare outcome characteristics.
Results
Fifty patients on the Surgery (19), Pediatrics (17), and Obstetrics & Gynecology (14) wards were monitored during their hospitalization. Characteristics significantly associated with the demand for healthcare were: polypharmacy during hospitalization, complication severity level, and whether a surgical intervention was performed.
Conclusions
A set of predictors of the demand for hospital care services was found applicable to different clinical specialties. These factors can all be identified during hospitalization and be used as a managerial tool to monitor the patients’ demand for hospital care services and to detect trends in time.
doi:10.1186/s12913-014-0674-2
PMCID: PMC4311505  PMID: 25608889
Patient characteristics; Demand for hospital care services; Time and motion research; (Multivariable) regression analysis
2.  Poststernotomy mediastinitis: a classification to initiate and evaluate reconstructive management based on evidence from a structured review 
Early recognition and, where possible, avoidance of risk factors that contribute to the development of poststernotomy mediastinitis (PSM) form the basis for successful prevention. Once the presence of PSM is diagnosed, the known risk factors have been shown to have limited influence on management decisions. Evidence-based knowledge on treatment decisions, which include the extent and type of surgical intervention (other than debridement), timing and others is available but has not yet been incorporated into a classification on management decisions regarding PSM. Ours is a first attempt at developing a classification system for management of PSM, taking the various evidence-based reconstructive options into consideration. The classification is simple to introduce (there are four Types) and relies on the careful establishment of two variables (sternal stability and sternal bone viability and stock) prior to deciding on the best available reconstructive option. It should allow better insight into why treatment decisions fail or have to be altered and will allow better comparison of treatment outcomes between various institutions.
doi:10.1186/s13019-014-0179-4
PMCID: PMC4247689  PMID: 25417190
Classification; Infection; Mediastinitis; Mediastinal infection; Outcomes; Poststernotomy; Postoperative; Sternal infection; Wound infection
5.  Factors and Models Associated with the amount of Hospital Care Services as Demanded by Hospitalized Patients: A Systematic Review 
PLoS ONE  2014;9(5):e98102.
Background
Hospitals are constantly being challenged to provide high-quality care despite ageing populations, diminishing resources, and budgetary restraints. While the costs of care depend on the patients' needs, it is not clear which patient characteristics are associated with the demand for care and inherent costs. The aim of this study was to ascertain which patient-related characteristics or models can predict the need for medical and nursing care in general hospital settings.
Methods
We systematically searched MEDLINE, Embase, Business Source Premier and CINAHL. Pre-defined eligibility criteria were used to detect studies that explored patient characteristics and health status parameters associated to the use of hospital care services for hospitalized patients. Two reviewers independently assessed study relevance, quality with the STROBE instrument, and performed data analysis.
Results
From 2,168 potentially relevant articles, 17 met our eligibility criteria. These showed a large variety of factors associated with the use of hospital care services; models were found in only three studies. Age, gender, medical and nursing diagnoses, severity of illness, patient acuity, comorbidity, and complications were the characteristics found the most. Patient acuity and medical and nursing diagnoses were the most influencing characteristics. Models including medical or nursing diagnoses and patient acuity explain the variance in the use of hospital care services for at least 56.2%, and up to 78.7% when organizational factors were added.
Conclusions
A larger variety of factors were found to be associated with the use of hospital care services. Models that explain the extent to which hospital care services are used should contain patient characteristics, including patient acuity, medical or nursing diagnoses, and organizational and staffing characteristics, e.g., hospital size, organization of care, and the size and skill mix of staff. This would enable healthcare managers at different levels to evaluate hospital care services and organize or reorganize patient care.
doi:10.1371/journal.pone.0098102
PMCID: PMC4039449  PMID: 24878506
6.  Which Reasons Do Doctors, Nurses, and Patients Have for Hospital Discharge? A Mixed-Methods Study 
PLoS ONE  2014;9(3):e91333.
Background
The decision to discharge a patient from a hospital is a complex process governed by many medical and non-medical factors, while the actual reasons for discharge frequently remain ill-defined.
Aim
To define relevant discharge criteria as perceived by doctors, nurses and patients for the development of a standard hospital discharge policy, we collected actual reasons and most pivotal medical and organisational criteria for discharge among all stakeholders.
Setting
A tertiary referral university teaching hospital.
Methods
We conducted a mixed methods analysis, using patient questionnaires, interviews and a focus group with caregivers, and observations during the daily rounds of doctors, nurses and patients during their hospital stay. Fourteen wards of the Surgery, Paediatrics and Neurology departments contributed.
Results
We observed 426 patients during their hospital stay. Forty doctors and nurses were interviewed, and 7 senior nurses attended a focus group. The most commonly used discharge criteria were clinical factors, organisational discharge issues and patient-related factors. A total of 269 patients returned their questionnaires. About one third of the adult patients and nearly half of the children (or their parents) felt their personal situation and assistance needed at home was insufficiently taken into account before discharge. Patients were least satisfied with the information given about what they were allowed to do or should avoid after discharge and their involvement in the planning of their discharge. Thus, besides obvious medical reasons for discharge, several non-medical reasons were signalled by all stakeholders as important issues to be improved.
Conclusions
A set of discharge criteria could be defined that is useful for a more uniform hospital discharge policy that may help reduce unnecessary length of stay and improve patient satisfaction.
doi:10.1371/journal.pone.0091333
PMCID: PMC3953385  PMID: 24625666
7.  Explaining the amount of care needed by hospitalised surgical patients: a prospective time and motion study 
Background
Hospitals provide care for patients with a variety of diseases, co-morbidities and complications. The actual amount of care these patients need is unclear. Given the recent developments such as ageing, multi-morbidity and budgetary restraints, a practical explanatory model would avail healthcare professionals and managers in determining the demand and costs for clinical care.
Methods
Six surgical wards in a Dutch university hospital participated in this prospective time and motion study. Surgeons, nurses and paramedics recorded the time spent on patient care 24/7 by means of PDAs. The investigators extracted possible determining characteristics from a previous systematic review and expert focus group. Total amount of care needed by the patients was expressed as costs involved in medical and nursing time, surgical interventions and diagnostics. Afterwards the investigators applied linear regression analysis to detect significant independent characteristics.
Results
174 Surgical patients were monitored during their hospital stay. Characteristics significantly influencing the consumed amount of care were: medication during hospitalisation, complications, co-morbidity, medical specialty, age, as well as undergoing surgery and length of stay. Median costs for care were €8.446 per patient admission.
Conclusions
The investigators developed a model that explains the total demand and costs of care needed for surgical patients in a university hospital. The input for this instrument can be derived from readily available data in hospital databases. This makes it a relatively easy instrument to help healthcare professionals and managers appreciate the amount of care needed on (surgical) wards and may be used to appreciate trends in time.
doi:10.1186/1472-6963-13-42
PMCID: PMC3599528  PMID: 23379756
Patient characteristics; Workload; Time and motion research; (multiple) regression analysis
8.  Framework of policy recommendations for implementation of evidence-based practice: a systematic scoping review 
BMJ Open  2013;3(1):e001881.
Objectives
Evidence-based practice (EBP) may help improve healthcare quality. However, not all healthcare professionals and managers use EBP in their daily practice. We systematically reviewed the literature to summarise self-reported appreciation of EBP and organisational infrastructure solutions proposed to promote EBP.
Design
Systematic review. Two investigators independently performed the systematic reviewing process.
Information sources
MEDLINE, EMBASE and Cochrane Library were searched for publications between 2000 and 2011.
Eligibility criteria for included studies
Reviews and surveys of EBP attitude, knowledge, awareness, skills, barriers and facilitators among managers, doctors and nurses in clinical settings.
Results
We found 31 surveys of fairly good quality. General attitude towards EBP was welcoming. Respondents perceived several barriers, but also many facilitators for EBP implementation. Solutions were proposed at various organisational levels, including (inter)national associations and hospital management promoting EBP, pregraduate and postgraduate education, as well as individual support by EBP mentors on the wards to move EBP from the classroom to the bedside.
Conclusions
More than 20 years after its introduction, the EBP paradigm has been embraced by healthcare professionals as an important means to improve quality of patient care, but its implementation is still deficient. Policy exerted at microlevel , middlelevel and macrolevel, and supported by professional, educational and managerial role models, may further facilitate EBP.
doi:10.1136/bmjopen-2012-001881
PMCID: PMC3563143  PMID: 23355664
Medical Education & Training
10.  Registration of surgical adverse outcomes: a reliability study in a university hospital 
BMJ Open  2012;2(3):e000891.
Objective
Accurate registration of adverse surgical outcomes is essential to detect areas for improvement of surgical care quality. One reason for inaccurate adverse outcome registration may be the method to collect these outcomes. The authors compared the completeness of the national complication registry database (LHCR) as used in our hospital with relevant information from other available resources.
Design
Retrospective reliability analysis.
Setting
University hospital.
Participants
From the 3252 patients admitted to the surgical wards in 2010, the authors randomly selected a cohort of 180 cases, oversampling those with adverse outcomes. The LHCR contains adverse outcomes as reported during morning hand-offs or in discharge letters. The authors checked if the number and severity of adverse outcomes recorded in the LHCR agreed with those reported in morning hand-offs, discharge letters and medical and nursing files.
Results
In 135 of 180 patients, all resources could be retrieved completely. Fourteen per cent of the patients with adverse outcomes were not recorded in the LHCR. Missing adverse outcomes were all reversible without the need for (re)operation, for example, postoperative pain, delirium or urinary tract complications. Only 38% of these adverse outcomes were reported in the morning hand-offs and discharge letters but were best reported in the medical and nursing files.
Conclusions
Registration of surgical adverse outcomes appears largely depending on the reliability of the underlying sources. For a more complete adverse outcome registration, the authors advocate a better hand-off and additional consultation of the patient's dossier. This extra effort allows for improvement actions to eventually avoid ‘mild’ adverse outcomes patients perceive as important and undesirable.
Article summary
Article focus
How complete is the national surgical complication registry as applied in a university hospital?
Should we use more or other resources to achieve a more complete registry of adverse outcomes?
Key messages
Registration of surgical adverse outcomes largely depends on the reliability of the underlying resources.
Better hand-off and additional consultation of the patient's dossier will increase the reliability.
This extra effort can help avoid ‘mild’ adverse outcomes patients perceive as important and undesirable.
Strengths and limitations of this study
Representative data set from a consistently used registry.
Only inhospital adverse outcomes were taken into account.
doi:10.1136/bmjopen-2012-000891
PMCID: PMC3367156  PMID: 22637372
11.  Which dressing do donor site wounds need?: study protocol for a randomized controlled trial 
Trials  2011;12:229.
Background
Donor site wounds after split-skin grafting are rather 'standard' wounds. At present, lots of dressings and topical agents for donor site wounds are commercially available. This causes large variation in the local care of these wounds, while the optimum 'standard' dressing for local wound care is unclear. This protocol describes a trial in which we investigate the effectiveness of various treatment options for these donor site wounds.
Methods
A 14-center, six-armed randomized clinical trial is being carried out in the Netherlands. An a-priori power analysis and an anticipated dropout rate of 15% indicates that 50 patients per group are necessary, totaling 300 patients, to be able to detect a 25% quicker mean time to complete wound healing. Randomization has been computerized to ensure allocation concealment. Adult patients who need a split-skin grafting operation for any reason, leaving a donor site wound of at least 10 cm2 are included and receive one of the following dressings: hydrocolloid, alginate, film, hydrofiber, silicone dressing, or paraffin gauze. No combinations of products from other intervention groups in this trial are allowed. Optimum application and changes of these dressings are pursued according to the protocol as supplied by the dressing manufacturers. Primary outcomes are days to complete wound healing and pain (using a Visual Analogue Scale). Secondary outcomes are adverse effects, scarring, patient satisfaction, and costs. Outcome assessors unaware of the treatment allocation will assess whether or not an outcome has occurred. Results will be analyzed according to the intention to treat principle. The first patient was randomized October 1, 2009.
Discussion
This study will provide comprehensive data on the effectiveness of different treatment options for donor site wounds. The dressing(s) that will prevail in effectiveness, satisfaction and costs will be promoted among clinicians dealing with such patients. Thus, we aim to contribute a well-designed trial, relevant to all clinicians involved in the care for donor site wounds, which will help enhance uniformity and quality of care for these patients.
Trial registration
http://www.trialregister.nl, NTR1849. Date registered: June 9, 2009
doi:10.1186/1745-6215-12-229
PMCID: PMC3219559  PMID: 21999705
12.  Topical haemostatic agents for skin wounds: a systematic review 
BMC Surgery  2011;11:15.
Background
Various agents and techniques have been introduced to limit intra-operative blood loss from skin lesions. No uniformity regarding the type of haemostasis exists and this is generally based on the surgeon's preference. To study the effectiveness of haemostatic agents, standardized wounds like donor site wounds after split skin grafting (SSG) appear particularly suitable. Thus, we performed a systematic review to assess the effectiveness of haemostatic agents in donor site wounds.
Methods
We searched all randomized clinical trials (RCTs) on haemostasis after SSG in Medline, Embase and the Cochrane Library until January 2011. Two reviewers independently assessed trial relevance and quality and performed data analysis. Primary endpoint was effectiveness regarding haemostasis. Secondary endpoints were wound healing, adverse effects, and costs.
Results
Nine relevant RCTs with a fair methodological quality were found, comparing epinephrine, thrombin, fibrin sealant, alginate dressings, saline, and mineral oil. Epinephrine achieved haemostasis significantly faster than thrombin (difference up to 2.5 minutes), saline or mineral oil (up to 6.5 minutes). Fibrin sealant also resulted in an up to 1 minute quicker haemostasis than thrombin and up to 3 minutes quicker than placebo, but was not directly challenged against epinephrine. Adverse effects appeared negligible. Due to lack of clinical homogeneity, meta-analysis was impossible.
Conclusion
According to best available evidence, epinephrine and fibrin sealant appear superior to achieve haemostasis when substantial topical blood loss is anticipated, particularly in case of (larger) SSGs and burn debridement.
doi:10.1186/1471-2482-11-15
PMCID: PMC3143913  PMID: 21745412
13.  Fracture Surgery of the extremities with the intra-operative use of 3D-RX: A randomized multicenter trial (EF3X-trial) 
Background
Posttraumatic osteoarthritis can develop after an intra-articular extremity fracture, leading to pain and loss of function. According to international guidelines, anatomical reduction and fixation are the basis for an optimal functional result. In order to achieve this during fracture surgery, an optimal view on the position of the bone fragments and fixation material is a necessity. The currently used 2D-fluoroscopy does not provide sufficient insight, in particular in cases with complex anatomy or subtle injury, and even an 18-26% suboptimal fracture reduction is reported for the ankle and foot. More intra-operative information is therefore needed.
Recently the 3D-RX-system was developed, which provides conventional 2D-fluoroscopic images as well as a 3D-reconstruction of bony structures. This modality provides more information, which consequently leads to extra corrections in 18-30% of the fracture operations. However, the effect of the extra corrections on the quality of the anatomical fracture reduction and fixation as well as on patient relevant outcomes has never been investigated.
The objective of this study protocol is to investigate the effectiveness of the intra-operative use of the 3D-RX-system as compared to the conventional 2D-fluoroscopy in patients with traumatic intra-articular fractures of the wrist, ankle and calcaneus. The effectiveness will be assessed in two different areas: 1) the quality of fracture reduction and fixation, based on the current golden standard, Computed Tomography. 2) The patient-relevant outcomes like functional outcome range of motion and pain. In addition, the diagnostic accuracy of the 3D-RX-scan will be determined in a clinical setting and a cost-effectiveness as well as a cost-utility analysis will be performed.
Methods/design
In this protocol for an international multicenter randomized clinical trial, adult patients (age > 17 years) with a traumatic intra-articular fracture of the wrist, ankle or calcaneus eligible for surgery will be subjected to additional intra-operative 3D-RX. In half of the patients the surgeon will be blinded to these results, in the other half the surgeon may use the 3D-RX results to further optimize fracture reduction. In both randomization groups a CT-scan will be performed postoperatively. Based on these CT-scans the quality of fracture reduction and fixation will be determined. During the follow-up visits after hospital discharge at 6 and 12 weeks and 1 year postoperatively the patient relevant outcomes will be determined by joint specific, health economic and quality of life questionnaires. In addition a follow up study will be performed to determine the patient relevant outcomes and prevalence of posttraumatic osteoarthritis at 2 and 5 years postoperatively.
Discussion
The results of the study will provide more information on the effectiveness of the intra-operative use of 3D-imaging during surgical treatment of intra-articular fractures of the wrist, ankle and calcaneus. A randomized design in which patients will be allocated to a treatment arm during surgery will be used because of its high methodological quality and the ability to detect incongruences in the reduction and/or fixation that occur intra-operatively in the blinded arm of the 3D-RX. An alternative, pragmatic design could be to randomize before the start of the surgery, then two surgical strategies would be compared. This resembles clinical practice better, but introduces more bias and does not allow the assessment of incongruences that would have been detected by 3D-RX in the blinded arm.
Trial registration
Dutch Trial Register NTR 1902
doi:10.1186/1471-2474-12-151
PMCID: PMC3152540  PMID: 21733185
Fracture; Wrist; Ankle; Calcaneus; Intra-operative imaging; 2D-fluoroscopy; 3D-imaging; Conebeam-CT; 3D-RX
14.  Hyperbaric Oxygen Therapy: Solution for Difficult to Heal Acute Wounds? Systematic Review 
World Journal of Surgery  2010;35(3):535-542.
Background
Hyperbaric oxygen therapy (HBOT) is used to treat various wound types. However, the possible beneficial and harmful effects of HBOT for acute wounds are unclear.
Methods
We undertook a systematic review to evaluate the effectiveness of HBOT compared to other interventions on wound healing and adverse effects in patients with acute wounds. To detect all available randomized controlled trials (RCTs) we searched five relevant databases up to March 2010. Trial selection, quality assessment, data extraction, and data synthesis were conducted by two of the authors independently.
Results
We included five trials, totaling 360 patients. These trials, with some methodologic flaws, included different kinds of wound and focused on different outcome parameters, which prohibited meta-analysis. A French trial (n = 36 patients) reported that significantly more crush wounds healed with HBOT than with sham HBOT [relative risk (RR) 1.70, 95% confidence interval (CI) 1.11–2.61]. Moreover, there were significantly fewer additional surgical procedures required with HBOT (RR 1.60, 95% CI 1.03–2.50), and there was significantly less tissue necrosis (RR 1.70, 95% CI 1.11–2.61). In one of two American trials (n = 141) burn wounds healed significantly quicker with HBOT (P < 0.005) than with routine burn care. A British trial (n = 48) compared HBOT with usual care. HBOT resulted in a significantly higher percentage of healthy graft area in split skin grafts (RR 3.50, 95% CI 1.35–9.11). In a Chinese trial (n = 145) HBOT did not significantly improve flap survival in patients with limb skin defects.
Conclusions
HBOT, if readily available, appears effective for the management of acute, difficult to heal wounds.
doi:10.1007/s00268-010-0923-4
PMCID: PMC3032900  PMID: 21184071
15.  Quality of life after laparoscopic and open colorectal surgery: A systematic review 
This study was a systematic review of the available evidence on quality of life in patients after laparoscopic or open colorectal surgery. A systematic review was performed of all randomized clinical trials (RCTs) that compared laparoscopic with open colorectal surgery. Study selection, quality assessment and data extraction were carried out independently by two reviewers. Primary endpoint was quality of life after laparoscopic and open colorectal surgery, as assessed by validated questionnaires. The search resulted in nine RCTs that included 2263 patients. Short- and long-term results of these RCTs were described in 13 articles. Postoperative follow-up ranged from 2 d to 6.7 years. Due to clinical heterogeneity, no meta-analysis could be conducted. Four RCTs did not show any difference in quality of life between laparoscopic or open colorectal surgery. The remaining five studies reported a better quality of life in favor of the laparoscopic group on a few quality of life scales at time points ranging from 1 wk to 2 years after surgery. In conclusion, based on presently available high-level evidence, this systematic review showed no clinically relevant differences in postoperative quality of life between laparoscopic and open colorectal surgery.
doi:10.3748/wjg.v16.i40.5035
PMCID: PMC2965279  PMID: 20976839
Quality of life; Colorectal surgery; Laparoscopy; Colonic neoplasms; Colonic diseases; Inflammatory bowel diseases
16.  Manual versus automatic bladder wall thickness measurements: a method comparison study 
World Journal of Urology  2009;27(6):747-753.
Purpose
To compare repeatability and agreement of conventional ultrasound bladder wall thickness (BWT) measurements with automatically obtained BWT measurements by the BVM 6500 device.
Methods
Adult patients with lower urinary tract symptoms, urinary incontinence, or postvoid residual urine were urodynamically assessed. During two subsequent cystometry sessions the infusion pump was temporarily stopped at 150 and 250 ml bladder filling to measure BWT with conventional ultrasound and the BVM 6500 device. For each method and each bladder filling, repeatability and variation was assessed by the method of Bland and Altman.
Results
Fifty unselected patients (30 men, 20 women) aged 21–86 years (median 62.5 years) were prospectively evaluated. Invalid BWT measurements were encountered in 2.1–14% of patients when using the BVM 6500 versus 0% with conventional ultrasound (significant only during the second measurement at 150 ml bladder filling). Mean difference in BWT values between the measurements of one technique was −0.1 to +0.01 mm. Measurement variation between replicate measurements was smaller for conventional ultrasound and the smallest for 250 ml bladder filling. Mean difference between the two techniques was 0.11–0.23 mm and did not differ significantly. The BVM 6500 device was not able to correctly measure BWTs above 4 mm.
Conclusions
Both BWT measurements are repeatable and agree with each other. However, conventional ultrasound measurements have a smaller measurement variance, can measure BWT in all patients, and BWTs above 4 mm.
doi:10.1007/s00345-009-0392-2
PMCID: PMC2780620  PMID: 19238399
Bladder wall thickness; Ultrasound; BVM 6500; Repeatability; Accuracy
17.  Intravenous fluid restriction after major abdominal surgery: a randomized blinded clinical trial 
Trials  2009;10:50.
Background
Intravenous (IV) fluid administration is an essential part of postoperative care. Some studies suggest that a restricted post-operative fluid regime reduces complications and postoperative hospital stay after surgery. We investigated the effects of postoperative fluid restriction in surgical patients undergoing major abdominal surgery.
Methods
In a blinded randomized trial, 62 patients (ASA I-III) undergoing elective major abdominal surgical procedures in a university hospital were allocated either to a restricted (1.5 L/24 h) or a standard postoperative IV fluid regime (2.5 L/24 h). Primary endpoint was length of postoperative hospital stay (PHS). Secondary endpoints included postoperative complications and time to restore gastric functions.
Results
After a 1-year inclusion period, an unplanned interim analysis was made because of many protocol violations due to patient deterioration. In the group with the restricted regime we found a significantly increased PHS (12.3 vs. 8.3 days; p = 0.049) and significantly more major complications: 12 in 30 (40%) vs. 5 in 32 (16%) patients (Absolute Risk Increase: 0.24 [95%CI: 0.03 to 0.46], i.e. a number needed to harm of 4 [95%CI: 2–33]). Therefore, the trial was stopped prematurely. Intention to treat analysis showed no differences in time to restore gastric functions between the groups.
Conclusion
Restricted postoperative IV fluid management, as performed in this trial, in patients undergoing major abdominal surgery appears harmful as it is accompanied by an increased risk of major postoperative complications and a prolonged postoperative hospital stay.
Trial registration
Current Controlled Trials ISRCTN16719551
doi:10.1186/1745-6215-10-50
PMCID: PMC2717956  PMID: 19583868
18.  Attitudes, Awareness, and Barriers Regarding Evidence-Based Surgery Among Surgeons and Surgical Nurses 
World Journal of Surgery  2009;33(7):1348-1355.
Background
Evidence-based surgery (EBS) is stressed to increase efficiency and health care quality, but not all surgeons and surgical nurses use EBS in clinical practice. To define future tailor-made interventions to improve evidence-based behavior, the aim of this study was to determine the attitude and awareness among surgeons and surgical nurses as to the paradigm of EBS and the barriers experienced when practicing EBS.
Methods
In this cross-sectional study, surgeons and surgical nurses at a university hospital in Amsterdam were invited to complete the BARRIERS scale and McColl et al. questionnaire. An evidence quiz was composed for the surgeons.
Results
Response rates were 67% (29/43) for surgeons and 60% (73/122) for nurses. Attitudes toward EBS were positive. Among the surgeons, 90% were familiar with EBS terms, whereas only 40% of the nurses were. Common barriers for surgeons were conflicting results (79%, 23/29) and the methodologic inadequacy of research reports (73%, 21/29); and for nurses they were unawareness of EBS (67%, 49/73) and unclear reported research (59%, 43/73). Only about half of the convincing evidence presented in the quiz was actually applied.
Conclusions
Surgeons have a positive attitude toward EBS and are familiar with EBS terminology, but conflicting results and methodologic shortcomings of research reports are major barriers to practicing EBS. Continual confrontations with available evidence through frequent critical appraisal meetings or grand rounds and using more aggregate sources of evidence are advocated. Nurses can probably benefit from EBS training focusing on basic skills. Finally, collaboration is needed among surgeons and nurses with the same zest about EBS.
doi:10.1007/s00268-009-0020-8
PMCID: PMC2691930  PMID: 19412569
19.  Design and development of a decision aid to enhance shared decision making by patients with an asymptomatic abdominal aortic aneurysm 
Objective
To design, develop, and evaluate an evidence-based decision aid (DA) for patients with an asymptomatic abdominal aortic aneurysm (AAA) to inform them about the pros and cons of their treatment options (ie, surgery or watchful observation) and to help them make a shared decision.
Methods
A multidisciplinary team defined criteria for the desired DA as to design, medical content and functionality, particularly for elderly users. Development was according to the international standard (IPDAS). Fifteen patients with an AAA, who were either treated or not yet treated, evaluated the tool.
Results
A DA was developed to offer information about the disease, the risks and benefits of surgical treatment and watchful observation, and the individual possibilities and threats based on the patient’s aneurysm diameter and risk profile. The DA was improved and judged favorably by physicians and patients.
Conclusion
This evidence-based DA for AAA patients, developed according to IPDAS criteria, is likely to be a simple, user-friendly tool to offer patients evidence-based information about the pros and cons of treatment options for AAA, to improve patients’ understanding of the disease and treatment options, and may support decision making based on individual values.
PMCID: PMC2770394  PMID: 19920978
decision support techniques; research design; program development; abdominal aortic aneurysm; decision making

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