Ward Group Research Articles

Clinical usefulness of bronchoalveolar lavage in patients with interstitial lung diseases: a pilot study

BackgroundBronchoalveolar lavage (BAL) is a useful tool in the diagnostic work-up of patients with interstitial lung diseases (ILDs). In this prospective study, we investigated the clinical usefulness of BAL in patients with ILD radiographically.MethodsThe enrolled patients were classified into outpatient department (OPD), and inpatients groups who was admitted to general ward (GW) or intensive care unit (ICU) groups based on the time when BAL done. The clinical usefulness of BAL was defined as a new diagnosis established and/or treatment significantly changed. The clinical usefulness of BAL among the three groups of patients and the patients divided by underlying diseases was compared using the χ2 test with or without Fisher’s exact test.ResultsAmong our 184 patients, there were 37 in OPD group, 86 in GW group and 61 in ICU group. The final diagnoses were infectious in 23, non-infectious in 102, mixed etiologies in 19, and non-diagnostic in 40 patients. The diagnostic yields (revised diagnosis after BAL) of BAL among ICU patients, GW patients and OPD patients were 60.6%, 69.7% and 21.6%, respectively (P<0.001), and was 57.1% in total patients. The diagnostic yields of BAL among patients with cancer, organ transplantation and collagen vascular disease were statistically different (P=0.009).ConclusionsBAL is of use in establishing a diagnosis of ILD and is mandatary especially in the admitted patients with ILD because diagnostic yield was relatively higher in admitted patients than in OPD patients. In addition, BAL should be done more early in the admitted patients with malignancy, stem cell and/or organ transplantation and collagen vascular disease especially when they showed poor response to initial medications.

Long-term mortality in the Intermediate care after emergency abdominal surgery (InCare) trial-A post-hoc follow-up study.

Patients undergoing emergency abdominal surgery are at high risk of post-operative complications. Although post-operative treatment at an intermediate care unit may improve early outcome, there is a lack of studies on the long-term effects of such therapy. The aim of this study was to assess the long-term effect of intermediate care versus standard surgical ward care on mortality in the Intermediate Care After Emergency Abdominal Surgery (InCare) trial. We included adult patients undergoing emergency major laparoscopy or laparotomy with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 10 or more, who participated in the InCare trial from October 2010 to November 2012. In the InCare trial, patients were randomized to either post-operative intermediate care or standard surgical ward care. The primary outcome was time to death within 6years after surgery. We assessed mortality with Coxregression analysis. A total of 286 patients were included. The all-cause 6-year landmark mortality was 52.8% (76 of 144 patients) in the intermediate care group and 47.9% (68 of 142 patients) in the ward care group. There was no statistically significant difference in mortality risk between the two groups (hazard ratio 1.06 (95% confidence interval 0.76-1.47), P=.73). We found no statistically significant difference in 6-year mortality between patients randomized to post-operative intermediate care or ward care after emergency abdominal surgery. However, we detected an absolute mortality risk reduction of 5% in favour of ward care, possibly due to random error.

PRIME study: Prescription review to impede medication errors.

Medication errors may account up to one-third of all medical errors in hospitals, thereby leading to adverse outcomes such as higher mortality rate and longer hospital stay. The primary objective of the study was to determine whether patient safety can be improved by clinical pharmacy services. The study also aimed to reveal whether medication errors can be prevented by any means. A prospective, observational study was conducted in a multispecialty hospital in India. Prescription audit was performed for patients followed by necessary intervention by the concerned physician. Chi-squared test, paired t-test and ANOVA were performed to test statistical significance. A total of 699 errors were encountered by 501 of 1149 patients enrolled. Prescription errors accounted for the majority (87.1%) of errors followed by administration (7.4%), transcription (4.3%) and dispensing (1.2%) errors. Average error per patient showed a significant gradual decline from baseline (2.08) to the final follow-up (1.06). ICU patients encountered a higher rate (52.8%) of errors than general ward group (42.8%), while geriatric population witnessed a low error rate (18.8%) compared to adults (72%). The study was not only successful in highlighting the impact of medication error assessment on patient safety, but it also demonstrated that medication errors can be lowered with the help of clinical pharmacy services. Findings from the study conclude that medication errors can be prevented if healthcare professionals are educated appropriately to avoid recurrence of past mistakes.

NANDA-I, NIC, and NOC taxonomies, patients' satisfaction, and nurses' perception of the work environment: an Italian cross-sectional pilot study.

Background and aim of the work:Structured nursing care planning, patients’ satisfaction with care, nurses’ job satisfaction, and the characteristics of the work environment may influence each other and impact on the quality of hospital care. This study aimed at investigating the differences in nurses’ perception of the work environment and patients’ satisfaction with care, between two groups of hospital wards that used NANDA-I, NIC, and NOC taxonomies or not in the daily practice.Methods:A pilot cross-sectional study was conducted involving nurses employed in eight wards of a teaching hospital in central Italy and patients hospitalized in these wards. The ‘Nursing Work Index Revised’ and the ‘Patient Satisfaction Scale’ were used to investigate nurses’ perception of the work environment and patients’ satisfaction with care, respectively.Results:Significant better perceptions of both the constructs were highlighted in those wards that used nursing taxonomies.Conclusions:The application of a healthcare model based on the nursing process methodology should be empowered in the hospital settings, since it can influence the quality of the environment and patients’ satisfaction with care. (www.actabiomedica.it)

The Effectiveness of Using Breathing Exercise on Sleep Quality Among Hospitalized Patients

Sleep disturbance among hospitalized patients has many factors especially at critical care units. Daily breathing exercises as pursed lip breathing (PLB) and diaphragmatic breathing improves sleep quality and reduces the occurrence of delirium. Aim of the study Evaluate the effectiveness of using breathing exercise on sleep quality among hospitalized patients. Design quasi experimental design. Sample A purposive sample including 152 patients were divided into four equal groups two from the Medical ward (study and control) 38 patients each group and two form the Medical Intensive Care Unit (MICU) (study and control) 38 each group at Minia university hospital. Results majority of the groups were male; all patients were in the middle age. (39% and 44.7%) of the medical ward groups (study and control) and (52.6% and 44.7%) respectively of the MICU groups had sever sleep problem. But after applying breathing exercise for 3 continuous days, the study groups (44.7%) of the medical ward and (50%) of the MICU had great sleep quality. Majority of study group’s patients at the medical ward and MICU had no Confusion,” with percentage (60.5% and 52.6%) respectively which mean no presence of delirium. Conclusion breathing exercise had significance effect on improving sleeping quality and reduce the occurrence of delirium among the study groups than the control groups.

Increased Psychiatric Risk in Children After Pediatric Intensive Care Unit Admission.

We aimed to assess psychiatric risk in children after admission to pediatric intensive care units (PICUs) and its association with greater psychiatric morbidity. We examined 130 children aged 6 to 13 years in a cross-sectional study divided into two groups: 65 children discharged from PICU and another 65 from general wards. The PICU group scored worse on all measured scales of psychiatric morbidities. The child-specific assessment methods included the posttraumatic stress disorder (PTSD) scale as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and Impact of Event Scale Revised for PTSD; Revised Children's Manifest Anxiety Scale for anxiety; and Birleson Depression Scale for depression. The PICU group had significantly higher frequencies of PTSD compared with the general ward group (84.6% vs. 6.2%, respectively; p < 0.001). Hence, PICU survivors have higher risk of psychiatric morbidities such as PTSD, anxiety, and depression compared with general ward patients.

Cost Savings and Efficacy in Management of Paracetamol Poisoning in a 23-hours Emergency Department Observation Unit: A Comparison to Inpatient Care.

IntroductionEmergency department observation units (EDOU) have been shown to be effective in decreasing hospitalization rates and length of stay (LOS) for various conditions. However, cost savings and efficacy in the management of poisoning in EDOU have not been widely studied. The objective of our study is to compare the costs and effectiveness of managing paracetamol poisoned patients in the EDOU with those treated in the inpatient wards.MethodsWe conducted a historical controlled observational study comparing paracetamol-poisoned patients (who received at least 21 hours of IV N-acetylcysteine [NAC]) admitted to the EDOU during 2013-2014 with similar patients admitted to inpatient ward during 2011, 2013-2014. ResultsWe found 136 patients admitted to the inpatient ward and 95 to our EDOU due to paracetamol poisoning but only 78 and 39 patients respectively fulfilled the inclusion criteria. Between the EDOU and inpatient ward groups, we found similar demographics, poisoning presentation, treatment, and adverse event profiles. There were no fatalities and only two patients (one from each group) developed hepatotoxicity. The "medical" length of stay was 31.9 hours shorter in the EDOU group compared to the inpatient ward group (23.3 versus 55.2 hours). EDOU patients have statistically significant savings (comparing bill size) of S$784 per patient.ConclusionsAdmission to the EDOU resulted in significant cost savings and 58% decreased LOS when compared to inpatient wards. The EDOU is a cost-effective and safe alternative for the management of selected paracetamol poisonings requiring NAC. Further studies would be needed to verify these results.

Analysis of infection composition and drug resistance to Gram-negative bacilli in children's respiratory tract in Suzhou from 2007 to 2016

Objective To analyze the infection composition and drug resistance to Gram-negative (G-) bacilli in children′s respiratory tract in Suzhou, in order to provide evidence for rational use of antibiotics clinically. Methods G- bacilli culture samples were collected from 21 561 cases of nasopharyngeal secretions from patients with respiratory tract infection admitted at the Department of Respiratory, Children′s Hospital of Soochow University from January 2007 to December 2016, including 21 246 cases in general wards, and 315 patients who were transferred to the respiratory department after treatment in the Intensive Care Unit(ICU), and the children were divided into the general ward group and the ICU group, and the pathogens were compared and the changes in bacterial susceptibility were dynamically observed between the 2 groups. Results The primary G-bacteria for respiratory infection was Haemophilus influenzae, followed by Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii.The detection rates of Klebsiella pneumoniae and Pseudomonas aeruginosa in the ICU group were 16.8% (21/125 strains)and 14.4%(18/125 strains), respectively, which were significantly higher than those in the general ward group [10.0%(208/2 071 strains), 9.2%(190/2 071 strains)]. The detection rates of G-bacteria in the ICU group were 33.7%(106/315 cases), which were significantly higher than those in the general ward group [9.4%(1 997/21 246 cases)], and the difference was statistically significant(χ2=210.325, P<0.001). The rare G-bacillus such as Stenotrophomonas maltophilia, Acinetobacter junii and Burkholderia onion were higher in the ICU group [17.6%(22/125 strains)] than that in the general ward group [6.4% (132/2 071 strains)]. The rate that of G-bacteria with two or more mixed infection in ICU group [17.0% (18/106 cases)] was significantly higher than in the general ward group [3.4%(68/1 997 cases)], and the difference was statistically significant(χ2=47.3, P<0.05). For the mixed infection, the ICU group was mainly composed of Klebsiella pneumoniae mixed with Pseudomonas aeruginosa or Escherichia coli, while the general ward group was composed of Haemophilus influenzae mixed with Pseudomonas aeruginosa or Escherichia coli.The sensitivity of Haemophilus influenzae to Ampicillin, Sultamicillin, Cefuroxime, Cefaclor and Azithromycin decreased, and the sensitivity to Chloramphenicol, Tetracycline and Trimethoprim+ Sulfamethoxazole increased year by year, and there were statistically significant differences in different years (all P<0.05). The sensiti-vity to Escherichia coli to Ceftazidime decreased year by year, and the sensitivity to Ampicillin and Levofloxacin increased year by year, and there were statistically significant differences in different years (all P<0.05). The sensitivity to Klebsiella pneumoniae to Cefoperazone/Sulbactam and imipenem decreased, and the sensitivity to Ciprofloxacin and Levofloxacin increased, and there were statistically significant differences in different years (all P<0.05). The sensitivity to Pseudomonas aeruginosa, Cefoperazone/Sulbactam and Ceftriaxone decreased year by year, and the sensitivity to Levofloxacin increased, and there were statistically significant differences in different years (all P<0.05). The detection rate of carbapenem-resistant strains of Klebsiella pneumoniae and Pseudomonas aeruginosa showed an increasing trend, and there were statistically significant differences in different years (all P<0.05). Conclusions The primary G-bacteria for respiratory infections is Haemophilus influenzae, G-bacilli especially, the mixed infection of G-bacilli, is more likely to cause severe and critical respiratory infections.The resistance rate of G-bacteria infection in children′s respiratory tract to commonly used antibiotics is generally on the rise. Key words: Gram-negative bacilli; Child; Respiratory tract; Drug resistance

Characteristics and outcomes of patients requiring airway rescue by the difficult airway response team in the emergency department and wards: A retrospective study.

Objective:In this retrospective cohort study, we aimed to determine the characteristics and outcomes of patients in the emergency department (ED) and wards who required emergency tracheal intubation by the difficult airway response team (DART).Materials and Methods:All patients between 18 and 80 years old receiving emergency tracheal intubation by the DART at a single tertiary referral hospital from January 2014 to December 2016 were reviewed and divided into ward and ED groups. Patient characteristics, comorbidities, indications for intubation, airway maintenance technique, and survival-to-discharge rates were analyzed and compared.Results:Totally, 192 patients (ward, n = 135; ED, n = 57) were eligible for the current study. Compared with the ward group, patients in the ED group were younger (58.9 ± 13 vs. 51.5 ± 15.6 years, P = 0.001), male-predominant (71.1% vs. 87.7%, P = 0.014), and had a higher incidence of trauma (6.7% vs. 22.8%, P = 0.001). The most common indications for tracheal intubation were respiratory distress (52.6%) and cardiac arrest (17.8%) in the ward group, and respiratory distress (31.6%) and airway protection (28.1%) in the ED group. Patients in the ED group received more fiberoptic intubations (42.1% vs. 17.8%, P = 0.039) and had a higher survival-to-discharge rate (87.7% vs. 44.4%, P < 0.001) than those in the ward group.Conclusions:Better recognition of differences in patient characteristics and indications for intubation in different units of the hospital may enable the DART to customize specialized equipment to improve efficiency and implement appropriate strategies for airway rescue to improve patient outcomes.

Collaboration and Satisfaction About Care Decisions in Team questionnaire-Psychometric testing of the Norwegian version, and hospital healthcare personnel perceptions across hospital units.

AimTo translate “The Collaboration and Satisfaction About Care Decisions in Team” questionnaire (CSACD‐T) into Norwegian and test it for psychometric properties. The further aim was to describe and compare healthcare personnel's collaboration and satisfaction about team decision‐making (TDM) across hospital units.DesignA cross‐sectional study.MethodsThe questionnaire was translated into Norwegian. A total of 247 healthcare personnel at two hospitals responded to the questionnaire. An explorative factor analysis was performed to test the factor structure of the questionnaire, while a Cronbach's alpha analysis was used to test for internal consistency. A one‐way ANOVA analysis and a Kruskal–Wallis test were applied to test for differences between hospital units.ResultsThe results demonstrate that the Norwegian version of the CSACD‐T has promising psychometric properties regarding construct validity and internal consistency. The mean score of the CSACD‐T was significantly higher in the maternity ward group than in the emergency room group.

Artificial Metalloenzymes Based on the Biotin-Streptavidin Technology: Enzymatic Cascades and Directed Evolution.

ConspectusArtificial metalloenzymes (ArMs) result from anchoring a metal-containing moiety within a macromolecular scaffold (protein or oligonucleotide). The resulting hybrid catalyst combines attractive features of both homogeneous catalysts and enzymes. This strategy includes the possibility of optimizing the reaction by both chemical (catalyst design) and genetic means leading to achievement of a novel degree of (enantio)selectivity, broadening of the substrate scope, or increased activity, among others. In the past 20 years, the Ward group has exploited, among others, the biotin–(strept)avidin technology to localize a catalytic moiety within a well-defined protein environment. Streptavidin has proven versatile for the implementation of ArMs as it offers the following features: (i) it is an extremely robust protein scaffold, amenable to extensive genetic manipulation and mishandling, (ii) it can be expressed in E. coli to very high titers (up to >8 g·L–1 in fed-batch cultures), and (iii) the cavity surrounding the biotinylated cofactor is commensurate with the size of a typical metal-catalyzed transition state. Relying on a chemogenetic optimization strategy, varying the orientation and the nature of the biotinylated cofactor within genetically engineered streptavidin, 12 reactions have been reported by the Ward group thus far. Recent efforts within our group have focused on extending the ArM technology to create complex systems for integration into biological cascade reactions and in vivo.With the long-term goal of complementing in vivo natural enzymes with ArMs, we summarize herein three complementary research lines: (i) With the aim of mimicking complex cross-regulation mechanisms prevalent in metabolism, we have engineered enzyme cascades, including cross-regulated reactions, that rely on ArMs. These efforts highlight the remarkable (bio)compatibility and complementarity of ArMs with natural enzymes. (ii) Additionally, multiple-turnover catalysis in the cytoplasm of aerobic organisms was achieved with ArMs that are compatible with a glutathione-rich environment. This feat is demonstrated in HEK-293T cells that are engineered with a gene switch that is upregulated by an ArM equipped with a cell-penetrating module. (iii) Finally, ArMs offer the fascinating prospect of “endowing organometallic chemistry with a genetic memory.” With this goal in mind, we have identified E. coli’s periplasmic space and surface display to compartmentalize an ArM, while maintaining the critical phenotype–genotype linkage. This strategy offers a straightforward means to optimize by directed evolution the catalytic performance of ArMs. Five reactions have been optimized following these compartmentalization strategies: ruthenium-catalyzed olefin metathesis, ruthenium-catalyzed deallylation, iridium-catalyzed transfer hydrogenation, dirhodium-catalyzed cyclopropanation and carbene insertion in C–H bonds. Importantly, >100 turnovers were achieved with ArMs in E. coli whole cells, highlighting the multiple turnover catalytic nature of these systems.

Systemic analysis of pre-hospital trauma emergency treatment in Zhengzhou

Objective: To analyze the data of pre-hospital emergency treatment in zhengzhou from 2007 to 2016, and evaluate the current situation of pre-hospital trauma emergency treatment, in order to provide a scientific basis for effective use of first aid resources and enhance success rate of trauma emergency treatment. Methods: Retrospective analysis was conducted based on pre-hospital emergency resources of Zhengzhou Emergency Medical Rescue Center from 2007 to 2016. Results: The total number of pre-hospital emergency treatment cases was 9 305 687 from 2007 to 2016 in Zhengzhou, of which 418 882 were trauma cases. The top five causes of injury were traffic accident injury, cutting injury, beating injury, crushing injury and falling injury. The top five emergency treatments used were oxygen, hemostasis, dressing and fixation, fluid supplementation, analgesics and sputum aspiration. According to different directions of diagnosis, the pre-hospital emergency patients were divided into four groups: emergency treatment group, emergency observation group, admission to general ward group and admission to ICU group. There was no statistical difference in the ages among the four groups (P>0.05). There were significantly statistical differences in gender composition among the four groups, with more males than females (P 0.05), but the mortality of the trauma, the average arrival time, and the mean treatment time were significantly different (P<0.01). Conclusions: The number of pre-hospital emergency trauma patients increased year by year, but the constituent ratio changed little. CRAMS score is important for the patients triage. Through the training of primary trauma care, the constituent ratio of death was reduced, and the average treatment time was shortened.

Exploration of “Talking Groups” within a medium secure setting

PurposeThe purpose of this paper is to explore patient and staff views of a new intervention “Talking Groups” within a medium secure setting.Design/methodology/approachSeven patients and eight members of staff who had attended Talking Groups in the medium secure wards participated in semi-structured interviews. Interviews were transcribed and analysed using thematic analysis.FindingsThe analysis revealed four key themes related to the aims, content and perceived benefits of Talking Groups: information; relationship building; engagement and patient involvement in developing activities/interventions.Practical implicationsIf Talking Groups are extended to other wards in the medium secure unit, information sessions should continue as part of the groups, as these were valued by patients and provided useful information about transition, human rights and medication.Originality/valueThe findings suggest that Talking Groups have benefits for patients and staff within this medium secure setting. Findings from this evaluation can be used to inform the development of Talking Groups across different wards in this unit.

Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit

The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown. To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward. Retrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics. Patient disposition on discharge from the ICU: directly home vs home via the hospital ward. The primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year. Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32% [295] vs 10% [594]; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42% [389] vs 34% [1984]; P < .001). In the propensity score matched cohort (n = 1632), patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42) but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35). The discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.

Circulating stem cells, HIF-1, and SDF-1 in septic abdominal surgical patients: randomized controlled study protocol

BackgroundSepsis caused by complicated intra-abdominal infection is associated with high mortality. Loss of endothelial barrier integrity, inflammation, and impaired cellular oxygen have been shown to be primary contributors to sepsis. To date, little is known regarding the pathway for the mobilization of endothelial progenitor cells (EPCs) from the bone marrow in sepsis whereas stromal-cell-derived factor 1a (SDF-1a) and hypoxia inducible factor 1 (HIF-1) seem to have a role in the EPC response to hypoxic microenvironments.The aims of the study are: (a) to determine the time course of the levels of circulating EPCs (CD133/CD34), SDF-1a, and HIF-1 in septic patients undergoing major abdominal surgery (group S), (b) to investigate the relationship between CD133/CD34, HIF-1, and SDF-1a, and (c) to investigate the relationship of these factors with the outcome of group S patients treated with standard conventional therapy alone (CT) or with the addition of extracorporeal hemoperfusion therapy (HCT).Methods/designPatients undergoing major abdominal surgery will be allocated into groups: postoperative non-septic patients in an emergency surgical ward (group C) and postoperative septic patients in an intensive care unit (group S). The latter will be randomized to receive CT alone (S1) or with HCT (S2). Healthy volunteers (group H) will be recruited at University Hospital Foggia.Peripheral blood (PB) samples will be collected preoperatively (T0), at 24 h (T1), 72 h (T2), 7 (T3), and 10 (T4) postoperative days in groups S and C, and at T0 in group H. The CD34/133 cells and HIF-1 counts will be determined by flow cytometer analysis. The concentration of SDF-1a in plasma will be calculated by enzyme-linked immunosorbent assay analysis (ELISA).DiscussionThis prospective randomized clinical trial is designed to investigate circulating stem cells, levels of HIF-1 and SDF-1a, and their interrelationship in septic postoperative abdominal surgical patients treated with CT alone or with HCT. The rationale is that an integrated understanding of the role of hypoxia-related factors and EPCs in PB of septic patients could indicate which molecular processes need to be regulated to recover the innate immunity homeostasis. Understanding the function of EPCs in sepsis may provide innovative diagnostic and therapeutic approaches to improve the prognosis of this syndrome.Trial registrationClinicalTrials.gov: NCT02589535. Registered on 28 October 2015.

Identifying positively deviant elderly medical wards using routinely collected NHS Safety Thermometer data: an observational study

ObjectiveThe positive deviance approach seeks to identify and learn from exceptional performers. Although a framework exists to apply positive deviance within healthcare organisations, there is limited guidance to support its...

Economic and organizational impact of a clinical decision support system on laboratory test ordering

BackgroundWe studied the impact of a clinical decision support system (CDSS) implemented in a few wards of two Italian health care organizations on the ordering of redundant laboratory tests under different perspectives: (1) analysis of the volume of tests, (2) cost analysis, (3) end-user satisfaction before and after the installation of the CDSS.Methods(1) and (2) were performed by comparing the ordering of laboratory tests between an intervention group of wards where a CDSS was in use and a second (control) group where a CDSS was not in use; data were compared during a 3-month period before (2014) and a 3-month period after (2015) CDSS installation. To measure end-user satisfaction (3), a questionnaire based on POESUS was administered to the medical staff.ResultsAfter the introduction of the CDSS, the number of laboratory tests requested decreased by 16.44% and costs decreased by 16.53% in the intervention group, versus an increase in the number of tests (+3.75%) and of costs (+1.78%) in the control group. Feedback from practice showed that the medical staff was generally satisfied with the CDSS and perceived its benefits, but they were less satisfied with its technical performance in terms of slow response time.ConclusionsThe implementation of CDSSs can have a positive impact on both the efficiency of care provision and health care costs. The experience of using a CDSS can also result in good practice to be implemented by other health care organizations, considering the positive result from the first attempt to gather the point of view of end-users in Italy.

Interdisciplinary Teamwork - The SMART Approach

Health care professionals are obligated to review their current practice and seek areas for development and improvement that are in line with current health care reforms and public expectation. In the current climate, the focus is on cost effective care that is safe, efficient and does not compromise patient outcomes. An example of innovative practice that strives to provide comprehensive care within the existing resources available is the Surgical and Medical Assessment & Rehabilitation Team (SMART) based in Beaumont hospital, Dublin. It is an interdisciplinary team, comprising of Occupational therapists and Physiotherapists, who have enhanced their existing work practices in order to improve timeliness and quality of therapeutic interventions. These two services provide assessment and rehabilitation services to the medical and surgical patients who are admitted to a busy city hospital. It is a mixed patient population across all age ranges and a variety of diagnostic groups. Through improved communication, timely interventions, duplication avoidance and utilisation of joint working opportunities, this team has created a template for care that could be transferred to many acute settings optimising service provision. This system provides increased support for team members improving morale and job satisfaction. Pre-implementation planning began three months in advance. The development of an interdisciplinary common assessment tool (CAT) was key to this change in practice. The CAT reduced unnecessary duplication of various profession specific assessments and captured vital information relating to patients social situation, premorbid and current functional status. The team launched on October 1st 2016. Operationally, the team meets twice daily to discuss and divide referrals between both disciplines. Meetings allow for more face to face interaction with team members and improved communication regarding ongoing patient care. One team member, be it the physiotherapist or the Occupational therapist then completes a CAT, identifies the needs of the patient in relation to therapeutic input and communicates this with their OT/PT counterpart. From this, a multidisciplinary plan for intervention is formulated. Therapists from each discipline are co-located to a certain group of wards maximising dual working and communication. Overall, this improves inter-professional working. Patients identified by these teams as requiring longer-term, focussed rehabilitation are discussed within the interdisciplinary meetings and transferred to a SMART Rehabilitation stream if deemed appropriate. When working to its full potential, team members reported greater awareness of the rehab needs and discharge plans of patients. While team members have offered much positive feedback on the new structure we acknowledge it is only in its infancy. An improvement in inter-professional communication has been noted as the most positive aspect with it subjectively leading to a perception of improved patient care. Sustainability of the service was challenged during its infancy during a time with a high level of both scheduled and unscheduled leave, coinciding with increased activity level in the hospital. During this period, improved team communication led to improved patient safety as decisions regarding priorities were made based on knowledge of the patient’s performance and discharge plans. This service is constantly evolving to meet the changing needs of the patient population and as a result there have been a number of changes to our documentation, team and meeting structures during the initial months. Change at interdisciplinary level relies on trust between professions and openness to challenging the norm. Both disciplines need to continue working together, constantly reflecting to ensure the smooth running of the team, while monitoring the effects it has on our level of patient care. Review and enhancement of operational processes and team structures is ongoing.

High-Flow Nasal Cannula in Bronchiolitis: Modeling the Economic Effects of a Ward-Based Protocol.

High-flow nasal cannula (HFNC) use has increased in patients with bronchiolitis, with the majority of use restricted to the ICU. Broadening HFNC to the wards may have substantial economic implications. This study compares the cost of a standardized clinical pathway that permits HFNC use in the wards for patients with bronchiolitis with an ICU-only HFNC care model. We constructed a decision analytic model to simulate 2 options for treating bronchiolitic patients: one in which HFNC is used in the wards (ward HFNC) and one in which HFNC is restricted to the ICU (ICU HFNC). The model inputs were based on patients admitted with bronchiolitis without major comorbidities between 2010 and 2015. 1432 patients were included for analysis. We simulated 10 000 patients for 5000 trials to assess parameter variability and sampling uncertainty, respectively. The primary outcome was average admission cost per patient. The secondary outcome was average length of stay (LOS) per patient. In the model, the average admission cost per patient for the ward HFNC group was $7020 (95% confidence interval [CI] $6840-$7194) compared with $7626 (95% CI $7427-$7839) in the ICU HFNC group, with a net difference of $606 (95% CI $408-$795). The average LOS for the ward HFNC group was 2.29 days (95% CI 2.24-2.33) compared with 2.61 days (95% CI 2.56-2.66) in the ICU HFNC group, with a net difference of 0.32 days (95% CI 0.27-0.37). Using HFNC in the ward for bronchiolitis may be cost-effective and may decrease LOS compared with ICU-only HFNC.

The effect of a preanaesthesia clinic consultation on adult patient anxiety at a tertiary hospital in Kenya: a cohort study.

Preoperative anxiety is a common perioperative complication seen in approximately 11-80% of adults undergoing surgery. One of the goals of the preanaesthesia clinic is to allay anxiety. A preanaesthesia clinic evaluation has been shown to reduce anxiety however current studies on anxiety and the preanaesthesia clinic have not quantified this reduction. To determine the reduction in anxiety in patients evaluated in the clinic versus those evaluated in the ward. Fifty one adult patients with 28 patients in anaesthesia clinic (AC) group and 23 in the ward (W) group were sequentially recruited from both the surgical, gynaecology and antenatal outpatient clinics and the wards. The patient's State Trait Anxiety Index (STAI) was taken once the patient was booked for theatre. The patients then had a preanaesthesia evaluation either in the preanaesthesia outpatient clinic (PAC) or in the wards. Another STAI score was taken in the preoperative area in theatre on the day of surgery. The difference in the change of STAI scores in both groups was then analysed. Fifty one adult patients were recruited with 28 in the AC group and 23 in the W group. The majority of patients were female (n=38). Statistically significant difference was seen in the reduction of the anxiety scores between the clinic group 2.143 (C.I=1.384-2.902) and ward group 0.74(C.I=0.17-1.31) with a p value=0.0051.There was also significant difference in reduction in anxiety scores within ward group in the patients with no prior anaesthetic experience having a greater reduction than those with prior anaesthetic experience. There were no other significant differences between the two groups. Patients evaluated in the anaesthesia clinic had a greater reduction in their anxiety but it was not as much as hypothesised which may be due to the multi-factorial nature of preoperative anxiety. A larger multicenter study is recommended to increase generalizability to the population.