The use of sedative-hypnotic drugs in a university teaching hospital.

We reviewed the charts of 476 patients admitted to a university teaching hospital to determine whether sedative-hypnotic drugs (SHDs) were being used excessively and to examine the use of SHDs as hypnotics. The frequency of medical and surgical indications for barbiturates and benzodiazepines or other minor tranquillizers as well as the use of such drugs were compared among different groups of patients and specialty wards. Of the patients 29% had a regular order and 40% had a PRN order; only 77% of the PRN orders were administered. A total of 215 patients (45%) received an SHD during their hospital stay, and 160 (34%) received the drug as a hypnotic. Medical indications accounted for 49% of the regular orders but only 2% of the PRN orders; moreover, 89% of all the PRN orders were for insomnia. On average, patients receiving SHDs as hypnotics were older (p less than 0.05) and stayed longer in hospital (p less than 0.01) than those who did not; however, no patient on the geriatric or pediatric ward received an SHD as a hypnotic during the hospital stay. The differences in use between patient groups may have been influenced by orientation of ward staff. Physicians should review their rationale for prescribing hypnotics and avoid routine orders on admission.     

Treatment of insomnia in demented nursing home patients: a review

Insomnia and fragmentation are features of the sleep of these patients. In order to list the factors disturbing the sleep of demented nursing home patients and the interventions improving their sleep quality, the literature was reviewed. A Medline search over the period 1966-2000 was performed. This resulted in 22 research articles. Admission to a nursing home is associated with sleep disturbances caused by patient problems (e.g. pain), care routines (e.g. nightly nursing round) and environment (e.g. noise). There are indications that the use of hypnotics in nursing home patients is not always effective and increases the risk of falls. There are several ways to reduce hypnotic consumption in nursing homes. Non-pharmacological interventions to decrease sleep disturbances caused by environmental factors have a favourable although weak effect on sleep itself. By reducing nightly noise, sleep quality does not necessarily improve. Light therapy seems to be the most effective non-pharmacological method to strengthen the circadian sleep/wake rhythm. The struggle against insomnia without using medication perhaps requires a two tracks management: detection and elimination of disturbing environmental factors and implementation of an adequate method to strengthen the circadian sleep/wake rhythm.     

Dependence on Hypnotic Drugs in General Practice

Of the patients in an industrial general practice 1.3% required hypnotic drugs regularly. They were predominantly in the older age groups (mean 62.7 years), with an excess of widows. Only 0.02% were severely dependent; the remainder were mildly so, though they had been taking hypnotics for long periods (mean 5.6 years). There were three main original indications for hypnotics—namely, medical (pain), psychiatric, and onset insomnia in anxious personality disorder. One-fifth of the patients first took hypnotics while in hospital. The group as a whole manifested a high degree of abnormal psychological disposition.It is suggested that many patients who take hypnotics regularly may be placebo reactors, and a more critical attitude to hypnotic prescribing is required both in hospital and in general practice.     

What did audit achieve? Lessons from preliminary evaluation of a year's medical audit.

OBJECTIVE--To evaluate the experience of a year''s audit of care of medical inpatients. DESIGN--Audit of physicians by monthly review of two randomly selected sets of patients'' notes by 12 reviewers using a detailed questionnaire dedicated to standards of medical records and to clinical management. Data were entered into a database and summary statistics presented quarterly at audit meetings. Assessment by improvement in questionnaire scores and by interviewing physicians. SETTING--1 District general hospital. PARTICIPANTS--About 40 consultant physicians, senior registrars, and junior staff dealing with 140 inpatient records. MAIN OUTCOME MEASURES--Median scores (range 1 to 9) for each item in the questionnaire; two sets of notes were discussed monthly at "general" audit meetings and clinical management of selected common conditions at separate monthly meetings. RESULTS--A significant overall increase in median scores for questions on record keeping occurred after the start of the audit (p less than 0.01), but interobserver variation was high. The parallel audit meetings on clinical management proved to be more successful than the general audits in auditing medical care and were also considered to be more useful by junior staff. CONCLUSIONS AND ACTION--Medical audit apparently resulted in appreciable improvements in aspects of care such as clerking and record keeping. Analysis of the scores of the general audits has led to the introduction of agreed standards that can be objectively measured and are being used in a further audit, and from the results of the audits of clinical management have been developed explicit guidelines, which are being further developed for criterion based audit.     

A comparative study of three hypnotics: methyprylon,glutethimide and chloral hydrate

A controlled study designed to evaluate the hypnotic potentiality of methyprylon (300 mg.), glutethimide (500 mg.) and chloral hydrate (1000 mg.) was carried out on 50 in-patients experiencing long-standing insomina. The patients ranged in age from 21 to 60 years, the sexes were equally represented and the clinical diagnoses were psychoneurosis, reactive depression, or anxiety reaction. An interesting feature of the experimental design allowed for the exclusion of placebo reactors before the initiation of the main trials. No difference in effectiveness of maintaining sleep could be established among the three hypnotic agents, indicating that at the usual levels of statistical significance, all three agents were equally effective as hypnotics. However, a significant trend (P = .05) was found for methyprylon (Noludar) to be the most effective and chloral hydrate to be the least effective of the three drugs in maintaining sleep. Methyprylon was found statistically (P = .05) to be the fastest sleep-inducing agent, whereas glutethimide (Doriden) proved to be the slowest of the three hypnotics with respect to sleep induction time.     

Evaluation of single-dose hypnotic treatment before elective operation.

A prospective randomised double-blind controlled trial was carried out to evaluate the place of a single dose of triazolam, flurazepam, and placebo on the evening before an elective operation in 96 patients. Features of sleep were recorded by patients and nurses on questionnaires. Onset of sleep was delayed and duration of sleep reduced in two-thirds of patients allocated placebo compared with their normal sleep pattern. Two-thirds of these patients also complained of waking more than twice during the night. Both hypnotics significantly improved the duration and time of onset of sleep and reduced the frequency of wakening when compared with the placebo. Patients who took triazolam, however, fell asleep faster and woke less often than those who took flurazepam. Furthermore, triazolam appeared to have advantages over flurazepam before surgery. Thus giving a single dose of a hypnotic on the night before an elective operation improves the patient''s sleep, and greater benefit was derived from triazolam than flurazepam.     

How valuable is feedback of information on hospital referral patterns?

OBJECTIVES--To determine general practitioners'' responses to and explanations for variation in rates of referral to hospital and how feedback of data on rates of referral could be used to facilitate practices in auditing their own referral behaviour. DESIGN--Visits by audit facilitators to general practices after feedback of details of rates of referral to hospital derived from annual reports in general practice. SETTING--92 general practices in East Anglia. RESULTS--General practitioners judged that access to specialist care, the individual skill of general practitioners, patient demand, and fear of litigation were major determinants of referral behaviour. Because there was widespread scepticism about the accuracy of the data on which the feedback was based and because there is no clear relation between rates of referral and quality of care, it was extremely difficult to encourage doctors to use the feedback as a basis for auditing their own hospital referrals. CONCLUSION--If general practitioners are to contribute meaningfully to monitoring future changes in referral patterns it will be essential to develop reliable information systems in which doctors have confidence. Furthermore, audits need to be based on analysis of clinical cases rather than on rates of referral.     

Clinical audits in a postgraduate general practice training program: an evaluation of 8 years' experience

Background

Clinical audit can be of valuable assistance to any program which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at evaluating audits'' effectiveness, valuable opportunities will be overlooked. Clinical audit projects are required as a part of the formative assessment of trainees in the Family Medicine Residency Program (FMRP) in Kuwait. This study was undertaken to draw a picture of trainees'' understanding of the audit project with attention to the knowledge of audit theory and its educational significance and scrutinize the difficulties confronted during the experience.

Methodology/Principal Findings

The materials included the records of 133 audits carried out by trainees and 165 post course questionnaires carried out between 2004 and 2011. They were reviewed and analyzed. The majority of audit projects were performed on diabetic (44.4%) and hypertensive (38.3%) care. Regarding audits done on diabetic care, they were carried out to assess doctors'' awareness about screening for smoking status (8.6%), microalbuminuria (19.3%), hemoglobin A1c (15.5%), retinopathy (10.3%), dyslipidemia (15.8%), peripheral neuropathy (8.8%), and other problems (21.7%). As for audits concerning hypertensive care, they were carried out to assess doctors'' awareness about screening for smoking status (38.0%), obesity (26.0%), dyslipidemia (12.0%), microalbuminuria (10.0%) and other problems (14.0%). More than half the participants (68.48%) who attended the audit course stated that they ‘definitely agreed’ about understanding the meaning of clinical audit. Most of them (75.8%) ‘definitely agreed’ about realizing the importance of clinical audit in improving patients'' care. About half (49.7%) of them ‘agreed’ that they can distinguish between ‘criteria’ and ‘standards’.

Conclusion

The eight years of experience were beneficial. Trainees showed a good understanding of the idea behind auditing the services provided. They demonstrated their ability to improve the care given in health centers in which these projects were undertaken.     

Survey of general practice audit in Leeds.

OBJECTIVE--To determine general practitioners'' attitudes to medical audit and to establish what initiatives are already being undertaken; to define future ideas for audit and perceived difficulties in implementing audit in primary care. DESIGN--Analysis of responses to a self administered postal questionnaire. SETTING--Urban conurbation with a population of about 750,000. PARTICIPANTS--386 general practitioners on the general medical list of Leeds Family Practitioner Committee. MAIN OUTCOME MEASURES--Extent of recording of practice activity data and outcome measures and clinical data, use of data, and audit performed; ideas for audit and perceived difficulties. RESULTS--317 doctors responded to the questionnaire (individual response rate 82%) from 121 practices (practice response rate 88%). In all, 206 doctors thought that audit could improve the quality of care; 292 collected practice activity data, though 143 of them did not use it. A total of 111 doctors recorded some outcome measures, though half of them did not use them. Varying proportions of doctors had registers, for various diseases (136 had at least one register), disease management policies (60 doctors), and prescribing policies. In all, 184 doctors met monthly with other members of the primary health care team. CONCLUSIONS--Much poorly focused data collection is taking place. Some doctors have experience in setting up basic information systems and practice policies, and some audit is being performed. The family health services authorities need to take seriously the perceived difficulties of time, organisation, and resources concerned with audit.     

Audit of the Medical Audit Committee.

We reviewed 39 medical audits started in one institution between 1981 and 1985 to determine whether they monitored the quality of health care in a scientific manner, whether recommendations were made that could improve the quality of health care and, if so, whether the recommendations were acted on. Thirty-three audits (85%) were completed; 21 (64%) failed to state their objectives, 30 (91%) failed to compare their results with those in the literature, 9 (27%) made no recommendations that could improve the quality of health care, and 9 were poorly researched and written. The number of patients in each audit was usually adequate. Feedback was rarely received by the Medical Audit Committee concerning the Medical Advisory Committee''s response to the audit. Information concerning the implementation of recommendations was available for 17 of the 24 audits that made recommendations; 7 (41%) had failed to implement half or more of the recommendations. Despite these problems, 8 (24%) of the audits were considered to be of a quality that could improve health care. We present recommendations to improve the audit procedure and foster the growing confidence among doctors in the medical audit.     

Benzodiazepine drugs in general medical patients.

Data from a hospital-based drug surveillance programme were used to determine how often benzodiazepine drugs were used in general medical wards. Benzodiazepines were the drugs most commonly used as hypnotics and were given to 32% of these patients. Concomitant use of more than one benzodiazepine drug or of benzodiazepines with other psychoactive drugs was common and often irrational. A series of double-blind patient-preference studies comparing various benzodiazepines and a benzodiazepine with an antihistamine showed that for short-term hypnotic effect there were no differences between three common benzodiazepines but elderly patients preferred benzodiazepines to the antihistamine, which produced more undesired effects. These results suggest that currently diazepam is the hypnotic of choice for medical ward inpatients.     

Oral care of people with disability: a qualitative exploration of the views of nursing staff

This study aimed to identify influences, attitudes and actions of nursing staff in relation to oral care for people with disabilities. Individual in-depth interviews of twenty two nursing staff were conducted. Enabling and inhibiting factors in the reported attitudes, approaches and practices were identified. The main enabling factors were that nursing staff saw mouth care as part of their role and took an empathic and caring approach to its delivery. They aimed to make the residents socially acceptable, improve their self-esteem and make their mouths clean and breath fresher. Inhibiting factors were: a lack of training, time constraints associated with workload, and poor understanding of the processes causing dental disease. The study concludes that improvements in oral care by nursing staff can be encouraged by working with nurses'attitudes, values and beliefs. Once the desired behaviour change has occurred then the lack of knowledge can be addressed.     

复方安神精油吸入给药的镇静催眠作用及化学成分的GC-MS分析

为研究复方安神精油吸入给药的镇静催眠作用,本实验采用动物自主活动测试和戊巴比妥钠诱导的睡眠潜伏期与睡眠时间实验:GC-MS分析复方安神精油的挥发性化学成分与入脑的主要化学成分;基于网络药理学预测和筛选出治疗失眠症相关靶蛋白与活性成分,旨在为复方安神精油治疗与改善失眠症提供理论依据。研究发现,复方安神精油具有镇静催眠作用,可显著减少动物自主活动,缩短睡眠潜伏期,延长睡眠时间;复方安神精油主要化学成分与入脑主要化学成分中含有多种具有神经中枢镇静催眠作用以及抗焦虑、抗抑郁作用的化学成分;基于网络药理学预测和筛选出25个治疗失眠症相关活性成分作用于39个治疗失眠症相关作用靶点,体现复方安神精油多成分、多靶点发挥镇静催眠作用的特点。     

Prescribing of psychoactive drugs for chronically ill elderly patients.

The prescribing of psychoactive drugs for 1431 chronically ill elderly patients being assessed for long-term institutional or community care was surveyed. Psychoactive drugs had been prescribed for about one quarter of the patients; benzodiazepines were the most frequently prescribed group. Judging from the extensive prescribing of flurazepam and chloral hydrate, commonly used hypnotics, the main reason psychoactive drugs were prescribed was to provide night-time sedation. Antidepressants and drugs promoted as useful in improving cognitive function were infrequently prescribed. Commendable prescribing practices included the infrequent use of "cerebral vasodilators" and barbiturates. Questionable prescribing practices included the infrequent use of tricyclic antidepressants in severely depressed patients and the use of tranquilizers in patients described by their attending physician as markedly or extremely withdrawn.     

Informal complaints procedure in general practice: first year's experience.

OBJECTIVE--To evaluate the first year''s experience of an informal patient complaints system that encourages extensive patient participation. DESIGN--Audit of an informal complaints procedure. SETTING--The Marylebone Health Centre, London. SUBJECTS--39 complaints received over the audit period. MAIN OUTCOME MEASURES--Types of complaints (administrative, about doctors or medical care or both, staff about patients, mixed, other) and resolution of complaints (how complaints were dealt with and their resolution). RESULTS--37 of the 39 complaints were resolved within two weeks. Two complaints sent direct to the family health services authority were resolved (with patients'' agreement) by the informal complaints procedure. CONCLUSIONS--The informal complaints procedure was more cost effective than the family health services authority system and was comparatively straightforward to implement within the practice without major organisational restructuring. The two way process of the procedure ensured patients received a quick response to complaints and helped morale of health centre staff.