(외과계열의) 모탈리티 컨퍼런스(Mortality Conference)의 질을 향상시킬 수 있을까? : 전향적 개입 연구(intervention study)

(출처 : http://usafamilymedicine.wordpress.com/tag/medical-industrial-complex/)

배경

세계적으로  환자 안전의 문제는 점차 더 많은 관심을 받고 있으며, 많은 연구에서 약 10%의 입원환자는 '부정적 사건(adverse event)'을 경험한다고 보고되고 있다. 그리고 이 중 절반 이상이 수술 과정과 관련되어 있고, 더욱 중요한 것은 대부분은 예방 가능하다는 것이다.

The issue of patient safety is receiving increasing attention worldwide, and numerous studies have shown that approximately 10% of patients admitted to a hospital suffer an adverse event.1 Over half of these adverse events are associated with a surgical procedure and, importantly, most are preventable.2–4

외과계열에서의 모탈리티 컨퍼런스(M&MC) - 종종 외과계열 교육의 핵심 이라고 불리우는 - 에서 의사는 의료 과오를 마주하게 된다. 그리고 이들 사건에 대해 열린 토론을 하고 다른 사람의 실수로부터 배운다. ACGME에 따르면 M&MC는 의무적으로 열려야 한다. 

The surgical morbidity and mortality conference (M&MC)—sometimes referred to as the cornerstone of surgical education—provides surgeons with an opportunity to confront medical errors, openly discuss adverse events, and learn from their mistakes and those of others.6,7 The M&MC is mandated by the Accreditation Council for Graduate Medical Education (ACGME)8 and complies with the Joint Commission requirement for ongoing professional practice evaluation.9

ACGME에서는 "매주 합병증과 사망에 대한 컨퍼런스를 매주 열 것"을 모든 외과계열에 요구하고 있으나, 구조나 내용 형식에 대해서는 과마다 크게 다르다. 예컨대 컨퍼런스를 통한 학습을 최대화 시키기 위한 표준화된 프리젠테이션 스타일이나 형식에 대한 가이드라인이 없다.

Although all academic surgery departments are required by the ACGME to hold a “weekly review of all complications and deaths,” the structure, content, and format of M&MCs vary widely by department. For example, there is no standardized presentation style or formal guideline for how to present surgical complications in a manner that maximizes the learning value of the M&MC. 

또한, 참석자가 컨퍼런스의 케이스로부터 얼마나 배웠는지를 평가하는 확실한 기준이 없어서 학습 도구로서의 M&MC의 효과성에 대한 연구 자료가 별로 없다. 우리는 ACGME의 현재 기준에 따라서 M&MC에 참석하는 것 만으로 학습을 하기에 충분한지에 대해 연구해보았다.

In addition, there are no robust measures or evaluations of what attendees learn from the presented cases and little data demonstrating the effectiveness of the M&MC as a learning or care improvement tool.10,11 We are particularly concerned that educators presume that attending an M&MC is sufficient for learning, given that the ACGME currently mandates that all educational activities provide measurable benefit in achieving core competencies.

Design

두 단계에 걸친 연구를 했다.

1단계 : 표준화된 근거 중심의 M&MC 발표 형식을 개발한다.

2단계 : 새로운 발표 형식을 도입한 후 전향적으로 그 효과에 대한 성과를 평가한다.

Our study had two phases:

• Phase 1: developing a standardized, evidence-based format for M&MC presentations

• Phase 2: conducting a prospective observational pre- and postintervention study to evaluate the effect of the standardized presentation format developed during Phase 1 on educational outcomes

결과

첫 번째로 종합적인, 근거 중심의, 구조화된 M&MC 프리젠테이션 형식을 만들었다.

We first developed a comprehensive, evidence based, structured format for M&MC presentations on the basis of the existing surgical literature and the SBAR framework.10,11,15–17

이것을 도입한 후, 프리젠테이션의 질적 향상이 있었다.

We noted significant improvements in presentation quality for three sections

교육적인 효과도 더 향상된 것으로 나타났다.

Educational outcomes also improved significantly after the intervention 

고찰

몇 가지 한계가 있다. 첫 번째로, 새로운 발표 방식 도입 전, 후 모두 발표자들은 자신의 발표가 평가된다는 것을 알고 있었다.

Our study has several limitations. First, presenters were aware that others were evaluating their presentations both before and after the intervention

두 번째로 작은, 하나의 기관에서만 이뤄졌다.

Next, our study was a relatively small, single-institution study, which could have resulted in faculty assessor observer bias

세 번째로, 대부분의 향상이 통계적으로는 유의미했지만, 절대적인 기준에서는 그다지 향상이 크지 않다.

Further, although the improvements we found were statistically significant, they were rather small in absolute terms

마지막으로, 교육적 성과 펴가는 발표 시점에서만 이뤄졌다.

Finally, we measured educational outcomes only at the time of the M&MC presentation.

이 연구의 결과는 medical community에 많은 시사점을 준다. M&MC는 의료 과오를 발견하고 어떻게 대처해야 하는지에 대해 논의하고 학습할 수 있는 근무 중심 학습의 좋은 기회이다.

Our findings from this study also carry implications for the larger academic medicine community. The M&MC represents an authentic, relevant, and contemporary workplace-based learning opportunity that offers the potential for peer learning and reflection on surgical care provision, such that medical errors and omissions can be identified and dealt with in a manner that prevents their reoccurrence and improves patient care

우리는 근거 중심의, 현실적인, 저렴한 도구를 개발했다.

We developed and evaluated an evidence-based, practical, and inexpensive tool that enhances the educational  outcomes of such conferences

이 간단한 개입만으로도 긍정적인 영향이 있었고, 비용적으로 저렴한 것은 많은 기관에서 장점으로 작용할 것이다.

This simple intervention can have a positive impact on practice-based education without overstretching hospital budgets, which is especially important today in a time of financial austerity for many institutions

마지막으로, 다른 사람들 역시 이 도구를 활용할 수 있다.

Finally, others can use the tool we developed to assess presentation quality to provide residents with formative feedback, and it can serve as a focus for presentation skills debriefing.

좀 더 validation된 tool을 원하는 교육학자들은 Objective Structured Assessment of Debriefing tool 을 사용해도 좋을 것이다.

Educators then can use the recently validated Objective Structured Assessment of Debriefing tool18 to evaluate these debriefings, linking presentation quality to educational outcomes.

M&MC는 초심자부터 전문가에 걸쳐 지식, 기술, 태도를 평가할 수 있는 좋은 기회이다. George Miller가 말한 것처럼 "단 하나의 도구로 전문가가 자신의 뛰어난(successful) 의술을 전수해주는 과정과 같은 수준의 복잡한 것을 평가할 수는 없다"

The M&MC provides an opportunity for educators to assess the knowledge, skills, and attitudes of trainees from novices to experts. As George Miller19 pointed out, there is “no single assessment method (that) can provide all the data required for the judgment of anything so complex as the delivery of professional services by a successful physician.” 

우리가 사용한 방법이 레지던트의 임상적 역량이나 performance를 바로 측정하지는 못하지만, M&MC는 레지던트가 그들의 지식과 능력을 임상 상황에서 적용하고 있는가를 평가할 수 있는 좋은 기회가 되는 것은 분명하다.

Our findings demonstrate that the M&MC can provide a forum for evaluating what trainees know and how they apply this knowledge to patient care. Although our tool does not directly evaluate residents’ clinical competence or performance, the M&MC itself provides the opportunity for educators to evaluate residents’ application and demonstration of their knowledge and ability to integrate that knowledge into their daily clinical practice.

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Acad Med. 2013 Jun;88(6):824-830.

Improving the Quality of the Surgical Morbidity and Mortality Conference: A Prospective Intervention Study.

Mitchell EL, Lee DY, Arora S, Kenney-Moore P, Liem TK, Landry GJ, Moneta GL, Sevdalis N.

Source

Dr. Mitchell is associate professor, Division of Vascular Surgery, Oregon Health & Science University School of Medicine, Portland, Oregon. Dr. Lee is currently a vascular surgeon at Cardiothoracic Surgeons, Kadlec Clinic, Richland, Washington. At the time of this study, he was a vascular surgery fellow, Oregon Health & Science University School of Medicine, Portland, Oregon. Dr. Arora is clinical lecturer in general surgery, Department of Surgery and Cancer, Imperial College London, London, England. Ms. Kenney-Moore is associate professor, Physician Assistant Program, Oregon Health & Science University School of Medicine, Portland, Oregon. Dr. Liem is associate professor, Division of Vascular Surgery, Oregon Health & Science University School of Medicine, Portland, Oregon. Dr. Landry is associate professor, Division of Vascular Surgery, Oregon Health & Science University School of Medicine, Portland, Oregon. Dr. Moneta is professor and chief, Division of Vascular Surgery, Oregon Health & Science University School of Medicine, Portland, Oregon. Dr. Sevdalis is senior lecturer in patient safety, Department of Surgery and Cancer, Imperial College London, London, England.

Abstract

PURPOSE:

Surgical morbidity and mortality conferences (M&MCs) provide surgeons with an opportunity to confront medical errors, discuss adverse events, and learn from their mistakes. Yet, no standardized format for these conferences exists. The authors hypothesized that introducing a standardized presentation format using a validated framework would improve presentation quality and educational outcomes for all attendees.

METHOD:

Following a review of the literature and the solicitation of experts' opinions, the authors adapted a validated communication tool-the SBAR (Situation, Background, Assessment, Recommendations) framework. In 2010, they then introduced this novel standardized presentation format into the surgical M&MCs at the Oregon Health & Science University. The authors assessed three outcome measures-user satisfaction, presentationquality, and education outcomes-before and after implementation of their standardized presentation format.

RESULTS:

Over the six-month study period, residents delivered 66 presentations to 197 faculty, resident, and medical student attendees. Attendees' performance on the multiple-choice questionnaires improved after the intervention, indicating an improvement in their knowledge. Presentation qualityalso improved significantly after the intervention, according to evaluations by trained faculty assessors. They noted specific improvements in thequality of the Background, Assessment, and Recommendation sections.

CONCLUSIONS:

The M&MC plays a pivotal role in educating residents and improving patient safety. Standardizing the M&MC presentation format using an adapted SBAR framework improved the quality of residents' presentations and attendees' educational outcomes. The authors recommend using such a standardized presentation format to enhance the educational value of M&MCs, with the goal of improving surgeons' knowledge, skills,and patient care practices.