Category Archives: FOAM

FOAM, General

ED Attendances: Win, lose or draw – Does it matter if England can’t score?

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This article was originally submitted to the Christmas BMJ and rejected as it wasn’t ‘interesting enough’. I’d forgotten I’d ever written it but reminded by the following tweet here is the original paper – please take it in the spirit in which it was originally intended!

The idea for the paper came from Ejiro Obakponovwe, who sadly passed away recently having developed ovarian cancer, I am sure she would have been delighted to see the paper released and if you do enjoy it please consider making a donation to a Joyful Joy – a charity she supported.

Presentations to Emergency Departments during a Major Football Championship:

Win, lose or draw – Does it matter if England can’t score?

Abstract:

Hypothesis: Anecdote suggests major sporting events reduce attendance at Emergency Departments. The poor performance of the English national side at this summer’s World Cup raised concerns that this was not occurring when England failed to win.

Objectives: To determine whether England match results during major football championships affect attendance at Emergency Departments

Design: A retrospective descriptive study

Setting: A busy city centre based Emergency Department

Data Sources: Attendances to the Resuscitation, Major, Minor and Paediatric areas were counted for the 8 hour period surrounding kick off time (4 hours either side) of World Cup and European Championship matches England played in events since 2004. These were matched against equivalent days in non-championship years.

Results: On average, the number of attendances to the Emergency Department around kick off on match days was 160 compared to 200 (Ratio 1.25, 95% CI 1.12 to 1.40). This reduction held true when the whole 24 hour period was considered (p=0.035). The trend was observed for categories of Minor (Ratio 1.51 (95% CI 1.28 to 1.77), p<0.0001) and Paediatric (Ratio 1.22 (95% CI 1.04 to 1.43), p=0.015) attendances but not Major (Ratio 0.96 (95% CI 0.82 to 1.12), p=0.578) or Resuscitation (Ratio 1.12 (95% CI 0.76 to 1.66), p=0.570). There was no evidence to suggest a difference in the number of total attendances between matches where England won or lost/drew (p=0.148).

Conclusions: The results indicate that staff in Emergency Departments should not have been concerned about England’s poor performance this summer as it did not increase their workload. Given an overall reduction in attendances the NHS should have an active interest in the England football squad and its management structure to ensure continued presence at World Cups and European Championships.

What is already known on this topic?

Although anecdote strongly supports the theory attendances to Emergency Departments decrease during major sporting events there is evidence to refute this.

Little research has examined the effect on the actual result of the English football team on attendances to Emergency Departments.

What this study adds?

A poor England performance does not appear to affect attendance although the public reduce their Minor or Paediatric attendances during championship matches in which England are playing. However they recognise that serious illness needs treating as demonstrated by the fact Major and Resuscitation area attendances are unaffected.

This may indicate the NHS should be interested in the future fortunes of the England team.

Introduction

Anecdote in Emergency Departments (EDs) often concerns a reduction of attendances when large sporting events are taking place. There is evidence to suggest this is not the case 1,2 and persons presenting with alleged physical assault to EDs may actually increase 3. The staff at the Leicester Royal Infirmary Emergency Department felt negative England performances were affecting attendances during this year’s disappointing World Cup campaign. Previous research in this area has only investigated presentations with alleged assaults when a national team played 4with increases following victories. We postulated that following an England loss attendances for minor injuries may increase in the hours following the game compared to matches in which England won (in the latter case the supporters’ physical pain is compensated by the enjoyment of celebrating).

Methods

The Leicester Royal Infirmary Emergency Department Information System (EDIS) was interrogated for attendance figures from 2004-2010. We extracted attendance data for each England match day (Table One) of the European Championships (Portugal 2004) and the World Cup (Germany 2006, South Africa 2010). Unfortunately England did not qualify for the 2008 European Championships. Attendances were categorised into Resuscitation, Major, Minor and Paediatric Group with the age and time of presentation also noted. Non-match days were identified for comparatives on the same day of the week in the following year (or a year earlier for 2010). Attendances, for the purpose of this study, were counted for the 8 hour period surrounding kick off time (4 hours either side).

Slide1

Poisson regression models, correcting for over dispersion, in SAS version 9.1.3 were used to compare the number of attendances between the 13 match days and the equivalent non-match days, both overall and by categories of Major, Minor, Child and Resuscitation. Poisson regression models also compared the number of attendances in ED on match days between matches where England won to matches where England drew or lost. No identifiable data was requested from the database.

Slide2

Results

Attendance data is demonstrated in Figures One and Two. There were a lower number of attendances in the 8 hour period surrounding match days compared to non-match days (p<0.0001). On average, this was 160 on match days compared to 200 on non-match days (Ratio 1.25, 95% CI 1.12 to 1.40). This trend was observed for categories of Minor and Paediatric attendances but not Major or Resuscitation (Table two). Using a matched pairs t test, there was also a lower average number of attendees in the 24 hours period of a match days compared to non-match days (p=0.035).

Slide3

There was no evidence to suggest a difference in the number of total attendances between matches where England won or lost/drew (p=0.148). This trend was observed for all categories (Table Three).

Slide4

Conclusion

Although there were only 13 available matches (England’s failure to qualify for the 2008 European championship reducing our dataset) it appears actual results impact little on attendance figures. Therefore staff not on shifts during match days should not feel too guilty about watching the match as the result is unlikely to be relevant to the department’s workload. In fact, as our results support the anecdote that attendances decrease, they may feel even less guilty. The general public appear to be able to tolerate the discomfort of a minor illness or injury on match days but perhaps do not feel strongly enough about England’s chances when faced with a more major complaint. The overall reduction in attendances indicates EDs, and perhaps the NHS, should strongly support the English Football Association’s attempts to secure England a strong manager into the next decade as this may well affect attendances and subsequently costs. This would be especially true if England do win the rights to host the 2018 event.

 

Many thanks to Suzanne Rafelt (Medical Statistician) and Patrick Walsh (Medical Student) at the University of Leicester for their initial help with the article.

Please consider making a donation to a Joyful Joy – a charity Ejiro supported.

 

 

FOAM, Social Media

Networking: Twitter doesn’t build communities, stories do…

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This blog posting is based on my talk to the #HSJRisingStars. It’s good to have the opportunity to expand on my thoughts as it’s clear from feedback that this didn’t quite touch the nerve I was expecting. Raising concerns about twitter, within twitter, is an interesting experience…

In the run up to NHS Change Day 2014 a number of constructive criticisms had been voiced on the type of pledges made. How can it be that health care professionals are pledging to “deliver safe care”, “create caring cultures”? Aren’t these pledges just paying lip service to the broader purpose? Are people just jumping on a bandwagon?

I wrote a blog in response to these concerns. It centred around my acknowledgement that on a busy shift I had forgotten to introduce myself to the parents/child I had just seen. I had essentially failed Kate Granger…

I am not a prolific blog writer, I’m probably not even a good one, but Kate tweeted the blog post and in the space of 3 hours it had received 1300 views. This was dissemination on a pretty impressive scale and in fact far more powerful than any previous networking opportunity I had been engaged in. It made me really think about reach and how I had communicated in and out of networks.

Change Day has taught us a lot about the NHS. There seems to be a unmet need to publicly discuss and celebrate core values; reports by Francis and Berwick have removed the taboo of some of these issues. It has taught me personally a great deal about my role in change and the roles of other networks. The story of Change Day began with a discussion about junior doctors and at the very first Change Day meeting I told a story inspired by Helen Bevan, describing how it is the new generation who are most likely to bring about radical change. Interestingly, though, one of the groups least involved in Change Day (in terms of raw numbers) were junior doctors (probably second only to GPs).

How did that happen? Did my networks fail to understand to the message? Was I wrong in my belief that Change Day can – and will – be a powerful instrument for cultural change? I think the reasons are subtle but well worth exploring.

Change Day was in essence about individual people. The real narrative was the reasons behind the individual pledges; the event itself was more like a big scrap book recording and highlighting more than half a million stories. My biggest transformation of thought in the last couple of years has been about the power of narrative. It’s personal narrative which drives us. The networks you are part of, represent, lead or create, contain people who share parts of that narrative. But I wonder how often your (or your network’s) narrative is shared by others. Just because I know ‘x‘ doesn’t necessarily mean that an e-mail by ‘x’ to their “network” will spread to a wider “network” and will be effective at spreading the message.

I’m sure I am as guilty as anyone at pushing the ‘send all’ button. Similarly asking friends  “can you send to your networks?” is something I have realised may not really add value. In fact the use of networks in this way may, in fact, create silos due to the lack of proper dialogue between them. “Nobody talks anymore” is oft quoted but there is some danger that it really is a little too easy not talk. By all means use technology – Hangout, FaceTime and Skype have enabled conversations to take place that weren’t possible previously. They are conversations with animation of expression and vocal nuance. But the real essence of good narrative goes beyond the physical conversation to the nature of what is being spoken. My story of failing at #hellomynameis is much more powerful than telling people how important Change Day is. Similarly describing my personal pledge is a much better vehicle to create interest than a newsletter about the day itself.

None of us wish to create silos as I’m sure we share the same the values. The translation of those values into a vision is probably different between our networks though. So in this time of social media and electronic interfaces, maybe we all need to be a bit more personal. We need to reconnect with each other with personal stories and communications that unite networks – not just transfer information between them.

“In this age of omniconnectedness, words like ‘network,’ ‘community’ and even ‘friends’ no longer mean what they used to. Networks don’t exist on LinkedIn. A community is not something that happens on a blog or on Twitter. And a friend is more than someone whose online status you check.” – Simon Sinek

This (admittedly controversial) quote was really brought home to me when I attended #SMACCGold, a social media and critical care conference. I thoroughly recommend watching the talks when realeased as they are all very much personal stories. Undoubtedly it was twitter, google and blogs that brought people in the #FOAMed community together but the real benefit for me was meeting the people there and engaging directly with them. As I said after the #HSJRisingStars event:

 

(Thanks to Natalie May for pre-publication proof-reading and editing)

FOAM, Medical Education, Social Media

#SMACCGOLD – It hurts..

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Too often we enjoy the comfort of opinion without the discomfort of thought

The 2nd SMACC (social media and critical care conference) has just finished. A packed 4 days (including pre-conference) with over 1000 delegates developed by a few brilliant individuals who have envisioned a different way of learning and collaborating.

This is no ordinary conference, with fantastic topics discussed and innovative events. See Salim Rezaie’s great blog for the detail. There are few conferences where professionally executed simulation debriefings occur in front of an entire auditorium, speakers’ cry in a context that feels appropriate and delegates give standing ovations in some of the break out sessions.

I sit writing this approaching Doha on the second stage of my journey home. I am a SMACC virgin, utterly humbled by the invitation to speak in Brisbane. I have met and listened to some extraordinary people but my over-riding emotion at the moment is one of sadness. I am truly sad it has finished. Don’t get me wrong, my youngest developed chicken pox during my journey away, I do want to go home. I am sad though that I know I will be attending other conferences (unfortunately SMACC Chicago is over a year away!) where I will sit and listen, I may learn some additional clinical information, I may meet a future research collaborator, if I am really lucky something may inspire me to change practice.

What is unlikely to happen is that there will be a tangible excitement when the first speaker takes to the stage, that over coffee break all the delegates will be smiling, that I will witness carefully constructed slide sets that support (not deliver) the stories the speakers are telling.

The attention to detail in the narratives delivered at SMACC was brilliant. It’s likely those reading this who weren’t at SMACC will probably be a little sceptical of this hyperbole. Please, please, watch the video casts when they are released. Watch how Cliff Reid and Iain Beardsell bring their emotional talks together full circle. Natalie May delivers to a packed crowd on “paediatric tips you won’t find in a book” using slides with no text and Tamara Hills received a standing ovation for her PK presentation.  Listen to Victoria Brazil deliver a 20 minute presentation in exactly 20 minutes with no timing aids (ok – I admit this is only probably considered really cool by geeks like me).

The hierarchical nature of academic events is not present at SMACC. It was brilliant to see a mix of professionals, grades, and specialities mucking in. Medical students and junior doctors delivering lectures and being part of the panel discussions. And so I could go on….

If there was one thing that encapsulated SMACC it was the patient centered approach to challenging dogma. I am struck that although the patient should be at the heart of everything we do – I often don’t see that at conferences. I hear people ‘talk’ about it but during lectures on new treatments or methods it’s about stats and facts. It’s about why the speaker thinks something is wrong. What SMACC did was deliver lectures where the speakers understood the challenges of normal practice. That patients are humans, that the things we do in critical and emergency care have an impact on them. That if we do what we always did, we will get where we are going – and is some cases that is simply not acceptable. Challenging Dogmalyis, championed by Prof. Simon Carley is uncomfortable. It hurts sometimes to be challenged.

SMACC hurt.

But until SMACC Chicago this type of hurt is so much better than the pain of any other conference you will go to….

Post Blog note:

Have already started getting messages saying but what about…..? Will start adding 🙂

FOAM

“Text, Slides and Videotape”: #SMACCGold Workshop Pre-reading

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The pre-conference workshops for #SMACCGOLD represent an opportunity for delegates to gain additional skills direct from some of the conference speakers

The Education Workshop contains a short session on “Text, Slides and Videotape” hosted by yours truly. The aim of this session is to aid delegates use of audio-visual tools to maximise the impact of their teaching. There will be lean towards the use of video as resources on other medium are easily found elsewhere (and its the area in which the greatest gains for least effort can be made IMHO)

I will also be offering an individual feedback session on videos/pictures used in teaching/assessment for attendees. Please send me your cases in advance (secure if needs be) and I’ll touch base at #SMACC. There might be a prize for the best use of audiovisual material for teaching….

It would be worthwhile for all participants to have a look at the following: (more will follow in the new year)

Resources

Education by Video 

P (cubed) A blog on Presentation Skills by Ross Fisher 

A literature review of Patient Video Cases (only for the seriously interested!)

ABC of learning and teaching in medicine

Tasks (these are not obligatory but will help inform the workshop)

1) Please register on www.spottingthesickchild.com (you’d don’t need to have any paediatric experience. This is to demonstrate videos in education. Orientate yourself to the site and then please go to

My waiting room > Patient Stories > Difficulty Breathing > Case 1

I’d like to start a discussion about this google + site.

2) I have added a test video to my vimeo site. It is password protected as the consent for this film means is only available to health care professionals. If you need a password please find it on the SMACC Education Google Discussion group or e-mail me on damianroland@me.com

Look forward to seeing you in 2014!

FOAM, Social Media

The #FOAMed universe – normal laws of evaluation don’t work here

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I try and write blogs which can be accessed by anyone, at anytime, with minimal prior knowledge. However in this case you probably do need a understanding of what #FOAM and it would be useful to also read @boringEM‘s thought provoking commentary on methods to evaluate #FOAMed sites. Essentially he proposes a number of metrics to evaluate, and potentially, rank #FOAMed resources. A number of tweets about this got me thinking of a potential conceptual challenge that may inhibit the debate:

https://twitter.com/njoshi8/status/348861858985414657

I have spent the last three years looking at the evaluation of practice changing interventions, in particular educational ones, as part of my PhD (see summary here). Part of this involved an analysis of the term evaluation, which is different from assessment and effectiveness. One of the things that happens when medics start evaluating things is that they often apply the same measures to a variety of different environments. As soon as discussions started on judging #FOAMed content inevitable comparisons with the process of evaluating academic literature arose (some of my previous comments on this here). The problem with that is:

i) Not only are #FOAM sites, by definition, designed to share learning in an OPEN access fashion but

ii) The methodology of engagement with #FOAMed was always going to be different from that of an academic paper.

To set some context the naysayers and skeptics for #FOAMed have always stated there is no quality control of resources. How do you know if the content holds up to current evidence? What if the authors are not credible or has a conflict of interest? Well – think of the last journal you read? Did you go away and practice immediately what it told you? I am fairly sure you didn’t, probably for a variety of reasons, but ultimately because critical evaluation has been ingrained in most clinicians from early in their training. This criticism  is a particular bug-bear of mine and puts people off receiving information via Social Media (see here for previous thoughts). The lack of peer-review of #FOAM material makes it more vital that the reader is aware of potential error (if I was to change one think it would be a universal alert statement is placed on site highlighting this – this would also act as a very useful #FOAM brand) but the reader can still make their judgement. As an example this paper on Early Warning Scores in Emergency Departments has been a cited on a number of occasions but is neither peer reviewed or commissioned, ultimately it should have no more value than anything else lifeinthefastlane.com or St.Emlyn’s have produced. Why does being in a journal make it have more value?

But I suppose I digress slightly, what is different about the evaluation? Well academic literature is spread by publication in journals, promoted by citations and only recently  encouraged by social media. #FOAM has always been essentially reliant on word-of-mouth. The route to #FOAM is rarely discussed. Think of the last #FOAMed site you went to – why did you go there? Did you just find it? I suspect (and please comment and say I have got this wrong) it’s because it is from a source you already follow or someone has directed you there. And who was that person? My guess it is someone  you trust,  follow or is a leader in #FOAM. Not really sure how you define a leader in #FOAM but I stake trust in the sites that key #FOAM supporters recommend. So if @sandnsurf, @emmanchester, @_nmay, @predordialthump, @boringem, @jvrbntz or @tessardavis mention a site I take a look. Others may have a completely different list – but it probably doesn’t matter who they are. There is a different form of peer review in process here – that of trusted followership.

Could there be mistakes in the process – well yes there could. But the process of academia and publication has not been risk free . So when it comes to evaluation the metric is at stake is the spread of information. The more recommendations leading to website hits being a proxy measure of word of mouth assessment of the perceived quality of site. Problems still exist if you want to be pedantic- hits to sites can be manipulated (but this can be controlled for) and the “quality”, in terms of readability and evidence, if you are determined to measure this as well has still not formally been assessed. But if you are evaluating  the primary purpose of FOAM then it is metrics like hits which have value. How this reflects the sharing ability of some of the FOAM leaders is open to question? This also prompts the question about what is the ultimate aim of #FOAM and whether it wishes to be constrained by old paradigms of evaluation or maybe create new ones.