Randomised controlled trial of GP-led in-hospital management of homeless people ('Pathway').

Homeless people have complex problems. GP enhanced care (Pathway) has shown benefits. We performed a randomised, -parallel arm trial at two large inner city hospitals. Inpatient homeless adults were randomly allocated to either standard care (all management by the hospital-based clinical team) or enhanced care with input from a homeless care team. The hospital data system provided healthcare usage information, and we used questionnaires to assess quality of life. 206 patients were allocated to enhanced care and 204 to usual care. Length of stay (up to 90 days after admission) did not differ between groups (standard care 14.0 days, enhanced care 13.3 days). Average reattendance at the emergency department within a year was 5.8 visits in the standard care group and 4.8 visits with enhanced care, but this decrease was not significant. -Quality of life scores after discharge (in 108 patients) improved with enhanced care (EQ-5D-5L score increased by 0.12 [95% CI 0.032 to 0.22] compared wtih 0.03 [-0.1 to 0.15; p=0.076] with standard care). The proportion of people sleeping on the streets after discharge was 14.6% in the standard care arm and 3.8% in the enhanced care arm (p=0.034). The quality-of-life cost per quality-adjusted life-year was £26,000. The Pathway approach doesn't alter length of stay but improves quality of life and reduces street -homelessness.

Urine protein estimation in hypertensive pregnancy: which thresholds and laboratory assay best predict clinical outcome?

OBJECTIVE: To determine what threshold for proteinuria could best predict clinical outcome and whether this threshold could be applied universally to any biochemical assay. DESIGN: A prospective observational study of hypertensive pregnancies referred for further assessment after in a UK University hospital (n=197). Twenty-four hour urine protein was measured by two different assays [benzethonium chloride assay (BCA) and Bradford assay]. The differences between the two assays were calculated from Receiver Operating Characteristic (ROC) curves. Commonly used thresholds for defining preeclampsia (0.3 and 0.5 g/24 hours) were explored for both assays for the prediction of adverse clinical outcomes (severe hypertension, Birthweight<10th percentile, preterm delivery, and a composite biochemical/haematological derangement). RESULTS: The two assays are not equivalent. The prevalence of>300 mg/24 hour proteinuria and, hence, the prevalence of preeclampsia differed between the two assays. ROC curve analysis demonstrates that the two assays are similar in terms of overall performance as predictive tests. However the threshold of 300 mg/24 hours performs poorly as a predictor of clinical risk. Likelihood ratios (LR) for the BCA at the 300 mg/L threshold for each clinical outcome do not achieve statistical significance. At the 500 mg/L threshold, the LR+for the BCA assay does achieve statistical significance for severe hypertension (LR+:1.51 95% CI 0.99-2.28) and for birthweight<10th percentile (LR+:1.72 95% CI 1.11-2.66). For the Bradford assay at the 300 mg/24 hour threshold, the LR+does achieve statistical significance for birthweight<10th percentile (LR+:1.71 95% CI 1.41-4.31). However, at the 500 mg/24 hour threshold, the LR+is significant for severe hypertension (LR+:2.15 95% CI 1.07-4.34), birthweight<10th percentile (LR+:2.79 95% CI 1.4-5.54) and biochemical disease (LR+:2.47 95% CI 1.22-5.01). CONCLUSIONS: This study suggests that thresholds for proteinuria need to be higher (possibly>or=0.5 g/24 hours) and there is the need for a "gold standard" proteinuria assay against which all other measures of quantification can be assessed.

Neutrophil intracellular pH and Na+/H+ exchanger activity in pre-eclampsia.

Elevated Na(+)/H(+) exchanger activity and intracellular acidosis have previously been demonstrated in white blood cells isolated from women who have suffered from a pre-eclamptic pregnancy. The mechanisms underlying this abnormality and the implications in pre-eclamptic pregnancies are, at present, unclear. In this study, we used neutrophils from third trimester pre-eclamptic patients and third trimester normotensive pregnant controls to determine Na(+)/H(+) exchanger isoform-1 (NHE-1) activity and intracellular pH. This was performed using a well-validated technique involving flurometry and a pH sensitive dye, 2,7'Bis-(carboxyethyl) 5.6 carboxyfluorescein acetomethyl ester (BCECF-AM). Time course experiments were performed to assess the contribution of plasma factors to intracellular pH measurements. Plasma digoxin-like factor (DLF) was assessed in both patients and normotensive controls. Neutrophil intracellular pH was significantly lower in the pre-eclamptic patients (7.15 +/- 0.050) compared with the normotensive pregnant controls (7.36 +/- 0.027; P<.001). NHE-1 activity (in mmol/L/min) was significantly higher in the pre-eclamptics (32.4 +/- 1.9) compared with the normotensive neutrophils (27.1 +/- 1.6; P =.038). Times course experiments showed that mean pre-eclamptic intracellular pH increased from 7.11 +/- 0.049 to 7.25 +/- 0.043 after 2 hours of incubation. DLF, measured as amount of inorganic phosphate liberated from adenosine triphosphate (ATP), was significantly lower when plasma from the pre-eclamptic patients was incubated with the enzyme compared with plasma from the normotensive pregnant women (54.9 +/- 2.6 nmol/mL plasma v 63.91 +/- 1.7 nmol/mL plasma, n = 6, P =.018 unpaired Student's t test). The results suggest that elevated NHE-1 activity and intracellular acidosis are intermediate phenotypes in women who have pre-eclampsia. Intracellular pH may have been affected by plasma as shown in the time course experiments. DLF, an inhibitor of Na(+)/K(+)ATPase, may contribute to this intracellular acidosis in pre-eclamptic neutrophils.

Validation of the DCA 2000 microalbumin:creatinine ratio urinanalyzer for its use in pregnancy and preeclampsia.

OBJECTIVE: To determine the accuracy of the DCA 2000 albumin/creatinine ratio urinanalyzer (Bayer Corp., Elkhart, IN) in uncomplicated pregnancy and preeclampsia. METHODS: This was a prospective observational study in a large teaching maternity hospital. Ninety one uncomplicated pregnant women and 100 women referred for assessment of de novo hypertension in pregnancy had albumin concentrations, creatinine concentrations, and albumin/creatinine ratios (ACR) compared between the DCA 2000 and the laboratory gold standard assays (Dade Dimension clinical chemistry autoanalyzer), for both early morning urines (EMU) and 24-hr urine collections. RESULTS: The interassay and intra-assay variability for the DCA 2000 were less than 5.1%. In uncomplicated pregnancy the mean difference in ACR between the DCA 2000 and the laboratory assay was 0.08 mg/mmol (SD 0.28; 95% limits of agreement, -0.47, 0.63) for EMU and 0.06 (SD 0.23; 95% limits of agreement, -0.39, 0.51) for 24-hr samples. In the hypertensive cohort the ACR mean differences were -0.82 (SD 7.13; 95% limits of agreement, -14.79, 13.15) for EMU and -0.76 (SD 4.14; 95% limits of agreement, -8.87, 7.35) for 24-hr samples. The mean differences between assays in the hypertensive group had broader 95% limits of agreement due to greater variability in the samples with high albumin concentrations (>40 mg/L). CONCLUSIONS: The DCA 2000 is accurate for the measurement of albumin creatinine ratios in the uncomplicated pregnant population. In the hypertensive population the DCA 2000 remains accurate though when the albumin concentration is greater than 40 mg/L the 95% limits of agreement are broader. We would recommend that all other automated urinalysis devices be validated by similar protocols to allow meaningful comparisons of accuracy.

Patient initiated home blood pressure recordings are accurate in hypertensive pregnant women.

OBJECTIVE: We undertook this study to determine the accuracy and reliability of patient initiated blood pressure measurement and recording. METHODS: We recruited 72 women from the antenatal hypertension clinic in a university teaching hospital. All were at high risk for preeclampsia and were asked to measure and record their blood pressure three times per day at home using a validated blood pressure device with an internal memory. RESULTS: From 979 measurements taken only 28 (2.9% were inaccurate). The inaccurate readings were restricted to three women. On further questioning two women admitted that the device had been used by other family members thus making comparison with the memory impossible. Thus the true nonconcordance rate amongst participants was 1/72 (1.4%). CONCLUSIONS: We conclude that blood pressure recordings taken and documented by high-risk women at home are accurate. This allows more frequent measurements to be taken without the inconvenience of additional visits to hospital and may therefore lead to the earlier detection of preeclampsia.

Hidden errors of aneroid sphygmomanometers.

BACKGROUND: Measurement of blood pressure remains the most commonly performed screening test in medical practice. With the likely removal of mercury sphygmomanometers from the workplace alternative devices are required. Of these the aneroid sphygmomanometer is popular both in the community and hospital setting. We investigated the accuracy of all the aneroid and mercury sphygmomanometers during dynamic calibration within a tertiary referral maternity hospital. METHODS: We compared the accuracy of 39 aneroid and 36 mercury sphygmomanometers to a recently calibrated and serviced mercury sphygmomanometer (the accepted gold standard). All devices were in current clinical use. Using three blinded, trained observers, 30 different pressures were checked throughout the pressure range following British Hypertension Society protocol guidelines. RESULTS: Only 31 (86%) of the mercury devices and 36 (92%) of the aneroid devices were in adequate working condition and suitable for analysis. Significantly more aneroid devices had systematic errors of > 5 mmHg (19 versus 3%, < 0.05). Fifty percent of aneroid devices had at least one reading > 10 mmHg out compared to only 10% of mercury devices (chi square programme). CONCLUSIONS: Aneroid sphygmomanometers in apparent good working order are inaccurate compared to mercury devices. Some of these faults can only be detected during dynamic testing. To minimize the risk of erroneous blood pressure recording, aneroid devices should be regularly checked for accuracy using dynamic calibration methods as recommended in validation protocols.

Emergency care. From zero to hero.

Essex Ambulance Service trust has achieved a rapid transformation, having last year received the country's worst CHI report. The trust transformed itself through new roles, collaborative working and developing its own model for out-of-hours services. Staff have new confidence in the management team, led by young, relatively inexperienced chief executive Anthony Marsh.

Life in the slow lane: making hospitals safer, slowly but surely.

Recognition that serious deficiencies in mutual respect and team work were hampering safe and effective patient care led to the creation of the cultural change initiative described here. We feel this has widespread applicability to other healthcare settings. The After Action Review (AAR) concept was adapted for use in the NHS for the first time as it provides a deceptively simple vehicle to structure healthy blame free team interactions with the aim of improving practice and team behaviours. The organizational and psychological barriers to being able to do this in multi-professional teams are accentuated by the hierarchical nature of the clinical context, but this project has begun to make lasting change so that AAR is an approach that is now widely understood and frequently used.

Why patients need leaders: introducing a ward safety checklist.

The safety and consistency of the care given to hospital inpatients has recently become a particular political and public concern. The traditional 'ward round' presents an obvious opportunity for systematically and collectively ensuring that proper standards of care are being achieved for individual patients. This paper describes the design and implementation of a 'ward safety checklist' that defines a set of potential risk factors that should be checked on a daily basis, and offers multidisciplinary teams a number of prompts for sharing and clarifying information between themselves, and with the patient, during a round. The concept of the checklist and the desire to improve ward rounds were well received in many teams, but the barriers to adoption were informative about the current culture on many inpatient wards. Although the 'multidisciplinary ward round' is widely accepted as good practice, the medical and nursing staff in many teams are failing to coordinate their workloads well enough to make multidisciplinary rounds a working reality. 'Nursing' and 'medical' care on the ward have become 'de-coupled' and the potential consequences for patient safety and good communication are largely self-evident. This problem is further complicated by a medical culture which values the primacy of clinical autonomy and as a result can be resistant to perceived attempts to 'systematize' medical care through instruments such as checklists.

Patient safety: culture eats strategy for breakfast.

'One morning recently, a professor conducted a ward round on an elderly medicine ward in a London teaching hospital. The entourage stopped at an 82-year-old man's bed. The elderly patient was confused and so, unfortunately, was the junior doctor who presented the case.