Auditing the effectiveness of Doctor-Patient communication - Srdjan Saso August 2008

A comparison of two orthopaedic units: one in a District General and one in a Teaching Hospital in the UK.

S Saso, C Doctor, S McNally, HDE Atkinson
Eastbourne District General Hospital and Northwick Park Hospital, UK


Background: Many studies and systematic reviews of the published literature over the past four decades have confirmed that good doctor-patient communication makes a significant difference not only to patient satisfaction but also to patient outcomes (1-5).
 
There was concern that effective communication was being compromised on our Orthopaedic wards for several reasons: firstly, due to the fast rate at which Orthopaedic ward rounds were carried out; secondly, due to the urgency of staff to get the patients to the operating theatre (shortening the time spent with the patients); thirdly, due to the often inappropriate assumptions that elderly patients had a degree of blindness, deafness or dementia and thus would not be able to comprehend their hospital management.
We wanted to assess whether these fears were real and compare findings between a London hospital: Northwick Park Hospital (NWPH) and a District General hospital outside London: Eastbourne District General Hospital (EDGH).
 
Method: We asked orthopaedic patients six questions as a very simple and efficient way of assessing the quality of communication between orthopaedic surgeons and patients. The audit was carried out in 2 hospitals as outlined above and 40 consecutive emergency admission patients with fractured necks of femur were interviewed in each.
 
Questions:
 
  1.  What is the name of your consultant?
  2.   Can you read the name badges of people who you see?
  3.   Have you been given any information leaflets?
  4.   What operation have you had/will you be having?
  5.   When is your expected discharge date?
  6. How well do you think you have been informed of you management by your doctors (Score 1 extremely poorly -10 exceptionally well)?
Gold Standard: “A patient should be able to answer all the questions following a ward round consultation, if adequate time has been spent with them and their queries have been addressed.”
The following was also audited: (a) Patient age and sex, (b) Length of hospital stay (c) Operation description. We used the following exclusion criteria: (a) Confused, demented, delirious, (b) Patients with an AMTS score < 8/10 and (c) Patients who had not yet been seen in an orthopaedic ward round.
 
Results: 40 patients with neck of femur fractures were asked the same questions at both NWPH and EDGH. The ratio of females to males was 31:9 at NWPH and 33:7 at EDGH. Most common surgical procedures were a DHS (47.5%; 30% respectively) and hemiarthroplasty (50%; 32.5% respectively). NWPH had mean hospital stays of 13 days, and EDGH of 12 days. Questions 1 and 2 were correctly answered by >60% of patients in both hospitals. Questions 3, 4 and 5 were correctly answered by between 32-45% of patients. Patients gave mean scores of 6/10 to question 6, with regards to how well informed they thought they were.

Question number NPH
number of correct answers (%)
EDGH
number of correct answers (%)
1 25 (62.5) 27 (67.5)
2 26 (65) 27 (65)
3 13 (32.5) 16 (40)
4 18 (45) 15 (37.5)
5 17 (42.5) 15 (37.5)
Mean correct 19.8 (49.5) 20 (50)
6 Mean 6 (60) Mean 6 (60)
 
Discussion: There was very little difference between the findings at NWPH and EDGH, with around 50% of patients being able to correctly answer the questions in both hospitals. The areas in which there was clear room for improvement were those highlighted by questions 3-5. The poor rate of patient ability to answer these questions we felt was in part explained by the fact that these questions required for more time to be spent with the patients. However it is interesting that the patients’ perceptions were that they were far better informed than they actually were (60% compared with mean correct scores of 50%).

Recommendations: All patients admitted with a fractured neck of femur should be started on an integrated care-pathway with a special care-pathway folder. We recommend that another sheet be inserted into this folder reminding the Orthopaedic staff to make sure patients that their patients are well informed about their fractures and their management. It is clear that more time should be spent with the patients on ward rounds, and in particular the patients should be informed what operation is being planned and more importantly their expected date of hospital discharge.
 
References

1) J Richards, P McDonald. Doctor-patient communication in surgery. J R Soc Med. 1985 November; 78(11): 922–924.
2) Maquire P, Pitceathly C. Key communication skills and how to acquire them. British Medical Journal 2002; 325:697-700.
3) Travaline J, Ruchinskas R, D’Alonzo G. Patient-Physician Communication: Why and How. Journal of the American Osteopathic Association 2005; 105:13-18
4) O'Neill J, Williams JR, Kay LJ. Doctor-patient communication in a musculoskeletal unit: relationship between an observer-rated structured scoring system and patient opinion. Rheumatology 2003; 42: 1518-1522
5) Indiana University. "Doctor-Patient Communication Has A Real Impact On Health." ScienceDaily 10 April 2007. 7 June 2008.


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