Friday, July 02, 2010

Lessons Learned From ICEM 2010 (Part F)

Lessons learned from:
Engaging Asia in Pediatric Emergency Medicine Multicentre Research – Opportunities and Challenges – by Dr. Fu Sheng

In this talk, Dr. Fu Sheng conceded that there is need for an Asian collaboration for pediatric emergency medicine research projects. Studies from western countries are not always applicable within the Asian context.

The Asian continent, with the biggest population group, has different sets of pediatric disease threats as compared to western countries. Infectious diseases are a prevailing cause of morbidity and mortality in many Asian countries. These include dengue and malaria.

Besides, Asian children seem to manifest disease responses differently. For example, the H1N1 infection seems to have a milder progression among Asian pediatric population. Thirdly, Asian countries have different sets of environmental-related diseases. Haze from forest fire in Indonesia results in respiratory diseases and this is a major problem in the South East Asia region.

Lastly, Asian countries also have different sets of problems related to their own socio-cultural perspective. He cited renal diseases related to melamine poisoning due to milk products consumption. He said that such projects should be cost-effective and pragmatic, to aim towards diagnosis, treatment and prevention of acute illnesses involving Asian children.

Lessons learned from:
Barriers and Enablers In Chest Pain Guidelines Implementation by Dr. Peter Pang

It is often unrealistic to expect everyone to change their clinical practice in order to follow a new guidelines or clinical pathway. In every organization and in every new implementation, there will be those who are the “early adopters” (willing to change), and there will be those who resist changes.

Dr. Peter Pang shared his experience during the implementation of chest pain guidelines in Hong Kong. In the very first place, one should a build a curriculum of Evidence-based medicine (EBM) culture in our local workplaces. And according to him, whenever we want to implement new guidelines, identify those “early adopters” – those that are willing to go the extra mile to support the changes. Invest in these “early adopters” with the hope that those who resist will sense the “observer effect”, thus, creating a hawthorne effect among these resistant ones.

He shared that in many occasions, the implementation process fails because the leaders themselves do not lead by examples. Leaders should do it themselves first. And those who are policy makers often do not get feedback and opinion from the grassroot users before implementing any guidelines. Thirdly he also shared that to create a sense of urgency to change, the guidelines must be clinically relevant, and the end users must see the urgent need themselves. For example, if the guideline is regarding issue related to life and death matters, then more people would be willing to follow. Implementing too many guidelines including those that have no clinical consequence will result in a low compliance rate. Fourthly, is the guideline user-friendly enough, easy to be remembered or is it rather taxing, complicated and results in many constraints in terms of manpower, time and facilities?

Dr. Peter Pang then came up with his own fishbone diagram to help him identify the reasons behind the implementation issues. The four categories of issues he studied, represented by four “bones” of the fish are: the Policy makers (+ stakeholders), the End-users, the Guideline characteristics, the Environment (Physical and social). He then used a to a Haddon Matrix approach chart to consolidate his findings.

Appendix: Fish bone diagram
My further literature search shows generic fishbone diagrams have been used to analyze cause-effects relationship. Also known as Ishikawa diagram, it was first described by Dr. Kaoru Ishikawa, a Japanese quality control statistician.

This fishbone diagram is an analysis tool that provides a systematic way of looking at effects and the causes that create or contribute to those effects.

The “head of the fish” represents the problem or issue to be studied. And each of the "bone of the fish" represent categories of causes that contribute to the problem. Typically they are remembered by the 4‘M’s: Methods, Machines, Materials, Manpower. Other ‘M’s frequently cited are: Mother Nature (Environment), Measurement (Inspection), Maintenance, Money Power, Management. Other variants include 4’S’s, 4’P’s, etc, etc (see Wikipedia: Ishikawa diagram. URL:

Haddon matrix, on the other hand, as many are well versed with, deals with prevention of diseases or injuries, etc. It has three phases: pre-event, event and post-event; and the factors are typically divided into Host or human, agent, environmental factors

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