Confidential inquiry into quality of care before admission to intensive care

Objective: To examine the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units, and to suggest possible solutions. Design: Prospective confidential inquiry on the basis of structured interviews and questionnaires. Setting: A large district general hospital and a teaching hospital. Subjects: A cohort of 100 consecutive adult emergency admissions, 50 in each centre. Main outcome measures: Opinions of two external assessors on quality of care especially recognition, investigation, monitoring, and management of abnormalities of airway, breathing, and circulation, and oxygen therapy and monitoring. Results: Assessors agreed that 20 patients were well managed (group 1) and 54 patients received suboptimal care (group 2). Assessors disagreed on quality of management of 26 patients (group 3). The casemix and severity of illness, defined by the acute physiology and chronic health evaluation (APACHE II) score, were similar between centres and the three groups. In groups 1, 2, and 3 intensive care mortalities were 5 (25%), 26 (48%), and 6 (23%) respectively (P=0.04) (group 1 versus group 2, P=0.07). Hospital mortalities were 7 (35%), 30 (56%), and 8 (31%) (P=0.07) and standardised hospital mortality ratios (95% confidence intervals) were 1.23 (0.49 to 2.54), 1.4 (0.94 to 2.0), and 1.26 (0.54 to 2.48) respectively. Admission to intensive care was considered late in 37 (69%) patients in group 2. Overall, a minimum of 4.5% and a maximum of 41% of admissions were considered potentially avoidable. Suboptimal care contributed to morbidity or mortality in most instances. The main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. Conclusions: The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to intensive care units may frequently be suboptimal. Major consequences may include increased morbidity and mortality and requirement for intensive care. Possible solutions include improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care.

Key messages

• Suboptimal management of oxygen therapy, airway, breathing, circulation, and monitoring before admission to intensive care occurred in over half of a consecutive cohort of acute adult emergency patients. This may be associated with increased morbidity, mortality, and avoidable admissions to intensive care
• At least 39% of acute adult emergency patients were admitted to intensive care late in the clinical course of the illness
• Major causes of suboptimal care included failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice
• A medical emergency team may be useful in responding pre-emptively to the clinical signs of life threatening dysfunction of airway, breathing, and circulation, rather than relying on a cardiac arrest team
• The structure and process of acute care and their importance require major re-evaluation and debate

     

Methods of pain sensitivity evaluation in the experiment and in clinical practice

In the article different methods of pain sensitivity evaluation are covered both in the experiment and in clinical practice, positive and negative sides are determined of different methods of pain sensitivity threshold determination.     

Using knowledge brokers to facilitate the uptake of pediatric measurement tools into clinical practice: a before-after intervention study

Background

There is a large quality of care gap for patients with osteoporosis. As a fragility fracture is a strong indicator of underlying osteoporosis, it offers an ideal opportunity to initiate investigation and treatment. However, studies of post-fracture populations document screening and treatment rates below 20% in most settings. This is despite the fact that bone mineral density (BMD) scans are effective at identifying patients at high risk of fracture, and effective drug treatments are widely available. Effective interventions are required to remedy this incongruity in current practice.

Methods

This study reviewed randomised controlled trials (RCT) involving fully qualified healthcare professionals caring for patients with a fragility fracture in all healthcare settings. Any intervention designed to modify the behaviour of healthcare professionals or implement a service delivery change was considered. The main outcomes were BMD scanning and osteoporosis treatment with anti-resorptive therapy. The electronic databases Medline and Embase were searched from 1994 to June 2010 to identify relevant articles in English. Post-intervention risk differences (RDs) were calculated for the main outcomes and any additional study primary outcomes; the trials were meta-analysed.

Results

A total of 2814 potentially relevant articles were sifted; 18 were assessed in full text. Nine RCTs evaluating ten interventions met the inclusion criteria for the review. All were from North America. Four studies focused on patients with a hip fracture, three on fractures of the wrist/distal forearm, and two included several fracture sites consistent with a fragility fracture. All studies reported positive effects of the intervention for the main study outcomes of BMD scanning and osteoporosis treatment. For BMD scanning the overall risk ratio (95% CI) was 2.8 (2.16 to 3.64); the RD was 36% (21% to 50%). For treatment with anti-resorptive therapy the overall risk ratio (95% CI) was 2.48 (1.92 to 3.2); the RD was 20% (10% to 30%).

Conclusions

All interventions produced positive effects on BMD scanning and osteoporosis treatment rates post-fracture. Despite sizeable increases, investigation and treatment rates remain sub-optimal. Long-term compliance with osteoporosis medications needs to be addressed, as the majority of studies reported treatment rates at six-month follow up only. Studies would be more informative if treatment criteria were defined a priori to facilitate understanding of whether patients were being treated appropriately and integrated economic analyses would be helpful for informing policy implementation decisions.     

An inquiry into the role of cardiac filling pressure in acclimatization to heat

During the first exposure of exercising subjects to hot environments (30-50 degrees C), cardiac output, heart rate, and body temperature increase over that seen in cool environments, while stroke volume decreases. If daily heat exposures occur, during the second heat exposure, heart rates and rectal temperatures are decreased from day 1 while cardiac output is maintained. This decrease in physiological strain occurs with little or no increase in evaporative heat loss. The alleviating agent appears to be an expansion of plasma volume. Several brief studies have indicated decreases in cardiac filling pressure during exercise in heat, and though inferential, it appears that the progressive increase in plasma volume during the first five to six days of heat exposure assists in maintaining cardiac filling pressure. Later, with increased evaporative heat loss due to increased sweat secretion, the mechanism of supplying increased volume to maintain cardiac filling is changed; fluid is transferred from extravascular to intravascular compartment, thus protecting venous return and cardiac filling pressure. These statements are based on limited data, and there is need of experiments designed to confirm or deny certain conclusions as to the role of cardiac filling pressure in acclimatization to heat.     

Public mental health: the time is ripe for translation of evidence into practice

Public mental health deals with mental health promotion, prevention of mental disorders and suicide, reducing mental health inequalities, and governance and organization of mental health service provision. The full impact of mental health is largely unrecognized within the public health sphere, despite the increasing burden of disease attributable to mental and behavioral disorders. Modern public mental health policies aim at improving psychosocial health by addressing determinants of mental health in all public policy areas. Stigmatization of mental disorders is a widespread phenomenon that constitutes a barrier for help-seeking and for the development of health care services, and is thus a core issue in public mental health actions. Lately, there has been heightened interest in the promotion of positive mental health and wellbeing. Effective programmes have been developed for promoting mental health in everyday settings such as families, schools and workplaces. New evidence indicates that many mental disorders and suicides are preventable by public mental health interventions. Available evidence favours the population approach over high-risk approaches. Public mental health emphasizes the role of primary care in the provision of mental health services to the population. The convincing evidence base for population-based mental health interventions asks for actions for putting evidence into practice.     

Characteristics of children presenting with chest pain to a pediatric emergency department.

Chest pain among children is a common complaint in primary care practice. However, the demographic features and treatment of such patients are controversial. We distributed a questionnaire to 336 consecutive patients with a complaint of chest pain seen during 1 year at an urban pediatric emergency department. Such visits represented 0.6% of all emergency encounters; the male:female ratio was 1.0. Physical examination was done in 325 patients. Chest-wall pain was the most common diagnosis (in 28% of cases). Other causes included pulmonary (in 19%), minor traumatic (in 15%), idiopathic (in 12%) and psychogenic (in 5%); miscellaneous causes (in 21%) most often indicated pain referred from the upper respiratory tract and the abdomen. The most common physical finding was chest tenderness (in 41% of cases). Investigations included chest radiography (in 50% of cases), electrocardiography (in 18%) and determination of the hemoglobin concentration and of the leukocyte count (in 13%); the results were rarely positive. Only eight patients (2%) required admission to hospital, and there were no cases of myocardial ischemia. The findings suggest that health care costs may be reduced by more judicious use of investigations. We conclude that chest pain is an uncommon and usually benign complaint in the pediatric emergency department. Most causes are evident on careful physical examination.     

Feasibility of a mental practice intervention in stroke patients in nursing homes; a process evaluation

Background  

Within a multi-centre randomised controlled trial in three nursing homes, a process evaluation of a mental practice intervention was conducted. The main aims were to determine if the intervention was performed according to the framework and to describe the therapists' and participants' experiences with and opinions on the intervention.     

Process evaluation of a tailored intervention programme of cardiovascular risk management in general practices

Background

A tailored implementation programme to improve cardiovascular risk management (CVRM) in general practice had little impact on outcomes. The questions in this process evaluation concerned (1) impact on counselling skills and CVRM knowledge of practice nurses, (2) their use of the various components of the intervention programme and adoption of recommended practices and (3) patients’ perceptions of counselling for CVRM.

Methods

A mixed-methods process evaluation was conducted. We assessed practice nurses’ motivational interviewing skills on audio-taped consultations using Motivational Interviewing Treatment Integrity (MITI). They also completed a clinical knowledge test. Both practice nurses and patients reported on their experiences in a written questionnaire and interviews. A multilevel regression analysis and an independent sample t test were used to examine motivational interviewing skills and CVRM knowledge. Framework analysis was applied to analyse qualitative data.

Results

Data from 34 general practices were available, 19 intervention practices and 14 control practices. No improvements were measured on motivational interviewing skills in both groups. There appeared to be better knowledge of CVRM in the control group. On average half of the practice nurses indicated that they adopted the recommended interventions, but stated that they did not necessarily record this in patients’ medical files. The tailored programme was perceived as too large. Time, follow-up support and reminders were felt to be lacking. About 20% of patients in the intervention group visited the general practice during the intervention period, yet only a small number of these patients were referred to recommended options.

Conclusions

The tailored programme was only partly used by practice nurses and had little impact on either their clinical knowledge and communication skills or on patient reported healthcare. If the assumed logical model of change is valid, a more intensive programme is needed to have an impact on CVRM in general practice at all.

     

From evidence to practice: development of web-based Dutch lipid reference values

IntroductionIn the Netherlands, the total number of yearly measured lipid profiles exceeds 500,000. While lipid values are strongly affected by age and sex, until recently, no up-to-date age- and sex-specific lipid reference values were available. We describe the translation of big-cohort lipid data into accessible reference values, which can be easily incorporated in daily clinical practice.MethodsLipid values (total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides) from all healthy adults and children in the LifeLines cohort were used to generate age- and sex-specific percentiles. A combination of RStudio, Cascading Style Sheets and HyperText Markup Language was used to interactively display the percentiles in a responsive web layout.ResultsAfter exclusion of subjects reporting cardiovascular disease or lipid-lowering therapy at baseline, 141,611 subjects were included. On the website, input fields were created for age, sex and all main plasma lipids. Upon input of these values, corresponding percentiles are calculated, and output is displayed in a table and an interactive graph for each lipid. The website has been made available in both Dutch and English and can be accessed at www.lipidtools.com.ConclusionWe constructed the first searchable, national lipid reference value tool with graphical display in the Netherlands to use in screening for dyslipidaemias and to reduce the underuse of lipid-lowering therapy in Dutch primary prevention. This study illustrates that data collected in big-cohort studies can be made easily accessible with modern digital techniques and preludes the digital health revolution yet to come.     

General practitioners' management of acute back pain: a survey of reported practice compared with clinical guidelines.

OBJECTIVE: To compare general practitioners'' reported management of acute back pain with ''evidence based'' guidelines for its management. DESIGN: Confidential postal questionnaire. SETTING: One health district in the South and West region. SUBJECTS: 236 general practitioners; 166 (70%) responded. OUTCOME MEASURES: Examination routinely performed, ''danger'' symptoms and signs warranting urgent referral, advice given, and satisfaction with management. RESULTS: A minority of general practitioners do not examine reflexes routinely (27%, 95% confidence interval 20% to 34%), and a majority do not examine routinely for muscle weakness or sensation. Although most would refer patients with danger signs, some would not seek urgent advice for saddle anaesthesia (6%, 3% to 11%), extensor plantar response (45%, 37% to 53%), or neurological signs at multiple levels (15%, 10% to 21%). A minority do not give advice about back exercises (42%, 34% to 49%), fitness (34%, 26% to 41%), or everyday activities. A minority performed manipulation (20%) or acupuncture (6%). One third rated their satisfaction with management of back pain as 4 out of 10 or less. CONCLUSIONS: The management of back pain by general practitioners does not match the guidelines, but there is little evidence from general practice for many of the recommendations, including routine examination, activity modification, educational advice, and back exercises. General practitioners need to be more aware of danger symptoms and of the benefits of early mobilisation and possibly of manipulation for persisting symptoms. Guidelines should reference each recommendation and discuss study methodology and the setting of evidence.     

Translating guidelines into practice: a systematic review of theoretic concepts,practical experience and research evidence in the adoption of clinical practice guidelines

OBJECTIVE: To recommend effective strategies for implementing clinical practice guidelines (CPGs). DATA SOURCES: The Research and Development Resource Base in Continuing Medical Education, maintained by the University of Toronto, was searched, as was MEDLINE from January 1990 to June 1996, inclusive, with the use of the MeSH heading "practice guidelines" and relevant text words. STUDY SELECTION: Studies of CPG implementation strategies and reviews of such studies were selected. Randomized controlled trials and trials that objectively measured physicians'' performance or health care outcomes were emphasized. DATA EXTRACTION: Articles were reviewed to determine the effect of various factors on the adoption of guidelines. DATA SYNTHESIS: The articles showed that CPG dissemination or implementation processes have mixed results. Variables that affect the adoption of guidelines include qualities of the guidelines, characteristics of the health care professional, characteristics of the practice setting, incentives, regulation and patient factors. Specific strategies fell into 2 categories: primary strategies involving mailing or publication of the actual guidelines and secondary interventional strategies to reinforce the guidelines. The interventions were shown to be weak (didactic, traditional continuing medical education and mailings), moderately effective (audit and feedback, especially concurrent, targeted to specific providers and delivered by peers or opinion leaders) and relatively strong (reminder systems, academic detailing and multiple interventions). CONCLUSIONS: The evidence shows serious deficiencies in the adoption of CPGs in practice. Future implementation strategies must overcome this failure through an understanding of the forces and variables influencing practice and through the use of methods that are practice- and community-based rather than didactic.     

Pharmacological evidence for the use of Cissus assamica as a medicinal plant in the management of pain and pyrexia

The existing therapeutic agents for the management of pain and pyrexia are not very efficient and accompanied by numerous side effects. Thus, new effective agents are the most needed. The present study investigates bioactivities and phytochemical screening of different parts of Cissus assamica (Vitaceae), a Bangladeshi tribal medicinal plant. Three plant parts stems, leaves and roots were collected, washed, dried, powdered and then prepared for cold extraction. The methanolic stems and leaves extracts were fractioned with four and two solvents respectively. Different plant extracts were then investigated for in vivo antinociceptive activity and only methanolic leaves extract was investigated for in vivo antipyretic activity. In Swiss-albino mice, 200 and 400 mg/kg body weight doses were used for all extracts. In the peripheral antinociceptive activity, the methanolic stem extract and its dichloromethane, chloroform, pet ether fractions and methanolic roots extract at their both doses showed significant antinociceptive responses when compared to standard diclofenac sodium (60.49% inhibition). In the central antinociceptive activity, the response was found significant for methanolic stem and methanolic roots extract in their both doses compared to standard morphine. In antipyretic activity, methanolic leaves extract significantly reduced pyrexia level at 400 and 200 mg/kg body weight doses after two, three and 4 h of administration when compared to standard. So our findings indicate that this plant possesses noteworthy pharmacological activities which may be a basis for further researches to establish a possible mode of action of its different parts.