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  • Gruen, Russell L.  (36)
  • Wiley (CrossRef)  (36)
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  • 1
    In: Journal of Evaluation in Clinical Practice, August 2011, Vol.17(4), pp.819-826
    Description: This qualitative study identifies cultural factors that influence the effective implementation of evidence‐based medicine (EBM) in surgical practice among Australian surgeons. In‐depth interviews ( = 22) were conducted with surgeons from a variety of specialties within a large hospital system in Victoria, Australia. The interviews explored the surgeons' understanding of EBM; and challenges to the adoption of EBM. The canons and procedures of the Miles and Huberman's Matrix Analyses approach to qualitative research guided the coding and organization of the data derived from the semi‐structured interviews. Surgeons had a good understanding of EBM, but viewed it as little more than a system of evidence, which was often divorced from actual clinical practice. The data also suggested that surgical culture(s) and typologies of surgical style were important variables in the implementation of EBM. The results suggest that the ideal method of EBM implementation is workplace instruction led by surgeons, who exhibit scientist and/or clinician styles of surgical practice; EBM training should occur early in the surgeons' careers; and EBM practice should be role modelled in the presence of trainees by surgeons who exhibit either a scientist and/or clinician style of surgical practice. The study findings suggest that using pre‐existing surgical culture(s) and styles is an important component in the implementation of EBM in surgery. The effective use of the scientist and/or clinician surgeon within the apprenticeship model and the context‐specific collegial networks of the surgical profession appear to be key elements in ensuring the successful implementation of EBM in surgery.
    Keywords: Ebm Training ; Epistemic Culture ; Implementation ; Hidden Curriculum ; Surgery
    ISSN: 1356-1294
    E-ISSN: 1365-2753
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  • 2
    In: Journal of Evaluation in Clinical Practice, August 2011, Vol.17(4), pp.678-683
    Description: Rural and remote surgical practice presents unique barriers to the uptake of the evidence‐based medicine (EBM) paradigm. As medical and education institutions around Australia develop practices and support for EBM, there are growing questions about how EBM is situated in the rural and remote context. The Monash University Department of Surgery at Monash Medical Centre implemented a study to explore the current understandings, attitudes and practices of rural surgeons towards the EBM paradigm. Descriptive survey of rural surgeons based in a tertiary care environment. The overall results of the survey demonstrate that: (1) rural surgeons have a good understanding of EBM; (2) EBM evidence is somewhat useful but not very important to clinical decision making; and (3) while rural surgeons are relatively confident in most sources listed, they are most confident in their own judgment and clinical practice guidelines, and least confident in telephone contact with colleagues. Rural surgeons’ understanding, usage and confidence in EBM purports that rural surgeons have contradictory, ambivalent and complex views of the EBM paradigm and its place in rural surgical practice. Professional isolation and context specificity are important to consider when extending the EBM paradigm to rural surgical practice and understanding the EBM uptake in the rural surgery context.
    Keywords: Attitudes And Training ; Evidence‐Based Medicine ; Rural ; Surgical Practice
    ISSN: 1356-1294
    E-ISSN: 1365-2753
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  • 3
    In: ANZ Journal of Surgery, March 2016, Vol.86(3), pp.167-172
    Description: Byline: Daniel T. Breen, Nuttaya Chavalertsakul, Eldho Paul, Russell L. Gruen, Jonathan Serpell Keywords: blood loss; elective; heparin; low-molecular-weight; surgical procedure; surgical; thromboembolism; warfarin Abstract Background Patients taking warfarin are often given interim anticoagulation in the perioperative period. Institutional guidelines that use low-molecular-weight heparin (LMWH) 'bridging' while the international normalized ratio (INR) is sub-therapeutic are often based on the American College of Chest Physicians Anticoagulation Guidelines. Purpose This study aims to identify if patients at a tertiary referral hospital were anticoagulated in line with these guidelines, and the incidence and nature of bleeding and thromboembolic complications. Methods A retrospective review of the Alfred Hospital General Surgical and 'Hospital at Home' databases was conducted, identifying patients who underwent elective general surgical procedures and received bridging anticoagulation with enoxaparin. Demographics, indication for anticoagulation, bleeding and thromboembolism rates were recorded. Thromboembolic risk was estimated. Results The study identified 108 patients. Three-quarters of all patients were anticoagulated with LMWH doses in accordance with the guidelines. Thirty of the 108 patients suffered bleeding complications. This group was younger, weighed less, received higher doses of enoxaparin and were at higher predicted risk of thromboembolism than non-bleeding patients. Wound haematoma, rectal bleeding and intra-abdominal bleeding were the most frequent complications. The peak time of bleeding was 3.5 days after surgery. Twelve patients returned to theatre, 13 were readmitted and 3 received blood transfusion. One patient suffered pulmonary emboli on the first post-operative day. Conclusion LMWH bridging therapy when prescribed appropriately is associated with low rates of inpatient thromboembolism in elective general surgical patients within our institution, but an unexpectedly high rate of bleeding complications. Article Note: D. T. Breen MBBS; N. Chavalertsakul MBBS; E. Paul MSc; R. L. Gruen MBBS, PhD, FRACS; J. Serpell MB, BS, MD, MEd, FRACS, FACS. This study is based on research presented at the 2012 RACS ASM.
    Keywords: Blood Loss ; Elective ; Heparin ; Low‐Molecular‐Weight ; Surgical Procedure ; Surgical ; Thromboembolism ; Warfarin
    ISSN: 1445-1433
    E-ISSN: 1445-2197
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  • 4
    Language: English
    In: Cochrane Database of Systematic Reviews, 02/15/2012
    Description: This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of EAAIs on patients with TBI.
    Keywords: Head Injury ; Treatment ; Pharmacological;
    ISSN: Cochrane Database of Systematic Reviews
    E-ISSN: 14651858
    Source: Wiley (via CrossRef)
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  • 5
    Language: English
    In: The Cochrane database of systematic reviews, 15 June 2011(6), pp.CD005528
    Description: Caesarean section rates are steadily increasing globally. The factors contributing to these observed increases are complex. Non-clinical interventions, those applied independent of patient care in a clinical encounter, may have a role in reducing unnecessary caesarean sections. To evaluate the effectiveness and safety of non-clinical interventions for reducing unnecessary caesarean sections. We searched the following electronic databases: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (29 March 2010), the Cochrane Pregnancy and Childbirth Group Specialised Register (29 March 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 2); MEDLINE (1950 to March 2010); EMBASE (1947 to March 2010) and CINAHL (1982 to March 2010). We included randomised controlled trials (RCTs), quasi-experimental studies, controlled clinical trials (CCTs), controlled before and after studies (CBAs) with at least two intervention and control sites, and interrupted time series analyses (ITS) where the intervention time was clearly defined and there were at least three data points before and three after the intervention. Studies evaluated non-clinical interventions to reduce unnecessary caesarean section rates. Participants included pregnant women and their families, healthcare providers who work with expectant mothers, communities and advocacy groups. Three review authors independently assessed the quality and abstracted data of all eligible studies using a standardised data extraction form, modified from the Cochrane EPOC checklists. We contacted study authors for additional information. We included 16 studies in this review.Six studies specifically targeted pregnant women. Two RCTs were shown to be effective in reducing caesarean section rates: a nurse-led relaxation training programme for women with a fear or anxiety of childbirth and birth preparation sessions. However, both RCTs were small in size and targeted younger mothers with their first pregnancies. There is insufficient evidence that prenatal education and support programmes, computer patient decision-aids, decision-aid booklets and intensive group therapy are effective.Ten studies targeted health professionals. Three of these studies were effective in reducing caesarean section rates. A cluster-RCT of guideline implementation with mandatory second opinion resulted in a small, statistically significant reduction in total caesarean section rates (adjusted risk difference (RD) -1.9; 95% confidence interval (CI) -3.8 to -0.1); this reduction was predominately in intrapartum sections. An ITS study of mandatory second opinion and peer review feedback at department meetings found statistically significant results at 48 months for reducing repeat caesarean section rates (change in level was -6.4%; 95% CI -9.7% to -3.1% and change in slope -1.14%; 95% CI -1.9% to -0.3%) but not for total caesarean section rates. A cluster-RCT of guideline implementation with support from local opinion leaders increased the proportion of women with a previous caesarean section being offered a trial of labour (absolute difference 16.8%) and the number who had a vaginal birth (VBAC rates) (absolute difference 13.5%). The P values are, however, not reported due to unit of analysis errors. There was insufficient evidence that audit and feedback, training of public health nurses, insurance reform, external peer review and legislative changes are effective. Implementation of guidelines with mandatory second opinion can lead to a small reduction in caesarean section rates, predominately in intrapartum sections. Peer review, including pre-caesarean consultation, mandatory secondary opinion and postcaesarean surveillance can lead to a reduction in repeat caesarean section rates. Guidelines disseminated with endorsement and support from local opinion leaders may increase the proportion of women with previous caesarean sections being offered a trial of labour in certain settings. Nurse-led relaxation classes and birth preparation classes may reduce caesarean section rates in low-risk pregnancies.
    Keywords: Cesarean Section -- Statistics & Numerical Data ; Unnecessary Procedures -- Statistics & Numerical Data
    E-ISSN: 1469-493X
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  • 6
    In: ANZ Journal of Surgery, March 2010, Vol.80(3), pp.157-161
    Description: There has been a shift from operative to conservative management of splenic injuries in the last two decades, but the current practice in Australia is not known. This study aims to determine the profile of splenic injury in major trauma victims and the approach to treatment in Victoria for the last 2 years. A review of prospectively collected data from the Victorian State Trauma Registry (VSTR) from July 2005 to June 2007 was conducted. Demographic data, details of the event, clinical observations, management and associated outcomes were extracted from the database. The patients were categorized into four groups according to management (conservative, splenectomy, embolization and repair) and were compared accordingly. Multivariate binary logistic regression was performed to identify predictors of treatment (conservative versus splenectomy) on arrival. Of the 318 major trauma patients with splenic injuries, 186 (59%) were treated conservatively, 103 (32%) with splenectomy, 17 (5%) with arterial embolization and 12 (4%) with repair. Of these, 14 (14%) splenectomy cases and 2 (12%) embolization cases did not receive their respective treatments within 24 h. The severity of the spleen injury (as measured by the Abbreviated Injury Scale (AIS)) and age were identified as significant independent predictors of the form of treatment provided. In Victoria, conservative management is the preferred approach in patients with minor (AIS = 2) to moderate (AIS = 3) splenic injuries. The low rates of embolization warrant further research into whether splenectomy is overused.
    Keywords: Conservative Management ; Embolization ; Epidemiology Of Splenic Injuries ; Spenorrhaphy ; Splenectomy
    ISSN: 1445-1433
    E-ISSN: 1445-2197
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  • 7
    Language: English
    In: The Cochrane database of systematic reviews, 30 March 2015(3), pp.CD009404
    Description: Specific clinical interventions are needed to reduce wrong-site surgery, which is a rare but potentially disastrous clinical error. Risk factors contributing to wrong-site surgery are variable and complex. The introduction of organisational and professional clinical strategies have a role in minimising wrong-site surgery. To evaluate the effectiveness of organisational and professional interventions for reducing wrong-site surgery (including wrong-side, wrong-procedure and wrong-patient surgery), including non-surgical invasive clinical procedures such as regional blocks, dermatological, obstetric and dental procedures and emergency surgical procedures not undertaken within the operating theatre. For this update, we searched the following electronic databases: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (January 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014), MEDLINE (June 2011 to January 2014), EMBASE (June 2011 to January 2014), CINAHL (June 2011 to January 2014), Dissertations and Theses (June 2011 to January 2014), African Index Medicus, Latin American and Caribbean Health Sciences database, Virtual Health Library, Pan American Health Organization Database and the World Health Organization Library Information System. Database searches were conducted in January 2014. We searched for randomised controlled trials (RCTs), non-randomised controlled trials, controlled before-after studies (CBAs) with at least two intervention and control sites, and interrupted-time-series (ITS) studies where the intervention time was clearly defined and there were at least three data points before and three after the intervention. We included two ITS studies that evaluated the effectiveness of organisational and professional interventions for reducing wrong-site surgery, including wrong-side and wrong-procedure surgery. Participants included all healthcare professionals providing care to surgical patients; studies where patients were involved to avoid the incorrect procedures or studies with interventions addressed to healthcare managers, administrators, stakeholders or health insurers. Two review authors independently assesses the quality and abstracted data of all eligible studies using a standardised data extraction form, modified from the Cochrane EPOC checklists. We contacted study authors for additional information. In the initial review, we included one ITS study that evaluated a targeted educational intervention aimed at reducing the incidence of wrong-site tooth extractions. The intervention included examination of previous cases of wrong-site tooth extractions, educational intervention including a presentation of cases of erroneous extractions, explanation of relevant clinical guidelines and feedback by an instructor. Data were reported from all patients on the surveillance system of a University Medical centre in Taiwan with a total of 24,406 tooth extractions before the intervention and 28,084 tooth extractions after the intervention. We re-analysed the data using the Prais-Winsten time series and the change in level for annual number of mishaps was statistically significant at -4.52 (95% confidence interval (CI) -6.83 to -2.217) (standard error (SE) 0.5380). The change in slope was statistically significant at -1.16 (95% CI -2.22 to -0.10) (SE 0.2472; P 〈 0.05).This update includes an additional study reporting on the incidence of neurological WSS at a university hospital both before and after the Universal Protocol's implementation. A total of 22,743 patients undergoing neurosurgical procedures at the University of Illionois College of Medicine at Peoria, Illinois, United States of America were reported. Of these, 7286 patients were reported before the intervention and 15,456 patients were reported after the intervention. The authors found a significant difference (P 〈 0.001) in the incidence of WSS between the before period, 1999 to 2004, and the after period, 2005 to 2011.  Similarly, data were re-analysed using Prais-Winsten regression to correct for autocorrelation. As the incidences were reported by year only and the intervention occurred in July 2004, the intervention year 2004 was excluded from the analysis. The change in level at the point the intervention was introduced was not statistically significant at -0.078 percentage points (pp) (95% CI -0.176 pp to 0.02 pp; SE 0.042; P = 0.103). The change in slope was statistically significant at 0.031 (95% CI 0.004 to 0.058; SE 0.012; P 〈 0.05). The findings of this update added one additional ITS study to the previous review which contained one ITS study. The original review suggested that the use of a specific educational intervention in the context of a dental outpatient setting, which targets junior dental staff using a training session that included cases of wrong-site surgery, presentation of clinical guidelines and feedback by an instructor, was associated with a reduction in the incidence of wrong-site tooth extractions. The additional study in this update evaluated the annual incidence rates of wrong-site surgery in a neurosurgical population before and after the implementation of the Universal Protocol. The data suggested a strong downward trend in the incidence of wrong-site surgery prior to the intervention with the incidence rate approaching zero. The effect of the intervention in these studies however remains unclear, as data reflect only two small low-quality studies in very specific population groups.
    Keywords: Medical Errors -- Prevention & Control ; Neurosurgical Procedures -- Adverse Effects ; Tooth Extraction -- Adverse Effects
    E-ISSN: 1469-493X
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  • 8
    Language: English
    In: Cochrane Database of Systematic Reviews, 01/19/2017
    ISSN: Cochrane Database of Systematic Reviews
    ISSN: 1469493X
    E-ISSN: 14651858
    E-ISSN: 1469493X
    Source: Wiley (via CrossRef)
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  • 9
    Language: English
    In: Cochrane Database of Systematic Reviews, 01/19/2011
    Description: This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effectiveness of interventions for managing skeletal muscle spasticity following TBI.
    Keywords: Head Injury ; Rehabilitation ; Nonpharmacological ; Pharmacological;
    ISSN: Cochrane Database of Systematic Reviews
    E-ISSN: 14651858
    Source: Wiley (via CrossRef)
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  • 10
    In: Journal of General Internal Medicine, November 2006, Vol.21(11), pp.1150-1155
    Description: Information technology (IT) has been advocated as an important means to improve the practice of clinical medicine. To determine current prevalence of non‐electronic health record (EHR) IT use by a national sample of U.S. physicians, and to identify associated physician, practice, and patient panel characteristics. Survey conducted in early 2004 of 1,662 U.S. physicians engaged in direct patient care selected from 3 primary care specialties (family practice, internal medicine, pediatrics) and 3 nonprimary care specialties (anesthesiology, general surgery, cardiology). Self‐reported frequency of e‐mail communication with patients or other clinicians, online access to continuing medical education or professional journals, and use of any computerized decision support (CDS) during clinical care. Survey results were weighted by specialty and linked via practice zip codes to measures of area income and urbanization. Response rate was 52.5%. Respondents spent 49 (±19) (mean [±standard deviation]) hours per week in direct patient care and graduated from medical school 23 (±11) years earlier. “Frequent” use was highest for CDS (40.8%) and online professional journal access (39.0%), and lowest for e‐mail communication with patients (3.4%). Ten percent of physicians never used any of the 5 IT tools. In separate logistic regression analyses predicting usage of each of the 5 IT tools, the strongest associations with IT use were primary care practice (adjusted odds ratios [aORs] ranging from 1.34 to 2.26) and academic practice setting (aORs 2.17 to 5.41). Years since medical school graduation (aOR 0.85 to 0.87 for every 5 years after graduation) and solo/2‐person practice setting (aORs 0.21 to 0.55) were negatively associated with IT use. Practice location and patient panel characteristics were not independently associated with IT use. In early 2004, the majority of physicians did not regularly use basic, inexpensive, and widely available IT tools in clinical practice. Efforts to increase the use of IT in medicine should focus on practice‐level barriers to adoption.
    Keywords: Information Technology ; Physician Practice Patterns ; Primary Care ; Academic Medicine
    ISSN: 0884-8734
    E-ISSN: 1525-1497
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