Streamlining the medication process improves safety in the intensive care unit.

BACKGROUND: Multiple interventions were made to optimize the medication process in our intensive care unit (ICU). 1 Transcriptions from the medical order form to the administration plan were eliminated by merging both into a single document; 2 the new form was built in a logical sequence and was highly structured to promote completeness and standardization of information; 3 frequently used drug names, approved units, and fixed routes were pre-printed; 4 physicians and nurses were trained with regard to the correct use of the new form. This study was aimed at evaluating the impact of these interventions on clinically significant types of medication errors. METHODS: Eight types of medication errors were measured by a prospective chart review before and after the interventions in the ICU of a public tertiary care hospital. We used an interrupted time-series design to control the secular trends. RESULTS: Over 85 days, 9298 lines of drug prescription and/or administration to 294 patients, corresponding to 754 patient-days were collected and analysed for the three series before and three series following the intervention. Global error rate decreased from 4.95 to 2.14% (-56.8%, P < 0.001). CONCLUSIONS: The safety of the medication process in our ICU was improved by simple and inexpensive interventions. In addition to the optimization of the prescription writing process, the documentation of intravenous preparation, and the scheduling of administration, the elimination of the transcription in combination with the training of users contributed to reducing errors and carried an interesting potential to increase safety.

[Medication errors on intensive care units: don't underestimate the risks due to transcription]. / Erreurs médicamenteuses aux soins intensifs: ne pas sous-estimer les risques dôs aux transcriptions.

UNLABELLED: INTRODUCTION; Medication errors [ME] can harm patients and increase costs. ME are frequent in the intensive care units (ICU], where patients are critically ill and therefore more vulnerable. Publications about ME in the critical care setting are rare. The differences between settings, the lack of standardized definitions and the use of different methods do not allow transposing published results to a specific ICU. The goal of this observational study is to analyse our local situation in relation to the literature findings and determine improvement opportunities. OUTCOMES: Rates of actual medication error [AME] and potential medication error [PME] per line of drug, and per patient-day. Distribution of errors among eight types considered clinically significant. CONTEXT: Intensive care unit, in a tertiary care hospital. METHOD: Error detection was based on the comparison between the prescriptions, the scheduling of the administrations [PME] and the actual medication administrations [AME). RESULTS: 229 lines with an AME were detected in 4636 lines of drugs administered to 144 patients during 373 patient-days. AME rate per line of drug was 5%. PME rate per line of drug was 17%. AME rate per patient-day was 61%. Dose omissions and not discontinued administrations accounted altogether for more than 50% of the total of AME. CONCLUSIONS: The literature does not consider the transcription stage as a priority target for error reduction, but this work shows that, depending on the context, transcriptions can significantly increase opportunities for errors. As transcription does not add any value, its suppression seems therefore to be an interesting target for medication safety improvement.

Home return 6 months after an intensive care unit admission for elderly patients.

BACKGROUND: Home return after critical care is very important not only to patients and families. To move back home, patients have to fulfill two conditions: survive, and have a relatively good functional status. In addition, home return could be considered a low-cost outcome because of the reduced permanent healthcare costs. METHODS: To determine the factors influencing the home-return probability of critically ill elderly patients 6 months after an intensive care unit (ICU) admission, we analyzed a cohort of patients aged 65 years or older admitted to an ICU. Demographic and social parameters, as well as admission diagnosis, underlying diseases, severity scores, ICU stay parameters, and complications were recorded. The final outcome was the place of stay (or death) 180 days after ICU admission. RESULTS: Of 526 patients, 72% of the cohort and 93% of hospital survivors were able to return to their homes. Among the variables used in the multivariate logistic regression, advanced age, length of hospital stay before ICU admission, severity of acute illness, diagnosis category, and complications, as well as certain comorbidities, such as chronic heart failure or a neoplasia, were independently negatively associated with a home return. CONCLUSION: Some interesting factors were identified in this single-center study. They could be considered for a multicenter study to build a universal prediction model for home return. Home return could be used for elderly patients as a surrogate for outcomes that are very important to the elderly but also to health politics.

[Latin organ donation programme (LODP): an effective initiative to increase organ donation in Switzerland]. / Programme latin de don d'organes (PLDO): une initiative efficace pour augmenter les dons d'organes en Suisse.

The 1st federal transplant law was enforced in July 2007 with the obligation to promote quality and efficiency in the procedures for organ and tissue donation for transplantation. The Latin organ donation programme (LODP) created in 2008 aims to develop organ donation in 17 public hospitals in 7 Latin cantons, covering 2.2 million people; 29% of the Swiss population. The implementation of various effective measures by the LODP enabled the increase in the number of donors by 70% between 2008 and 2010, with four organs procured per donor; greatly exceeding the European average of three. The results show that LODP has successfully professionalised the system and we can only hope that similar organisations will be put into place throughout Switzerland.

Improving nutritional therapy of persistent critically ill patients by organisational measures: A before and after study.

BACKGROUND & AIMS: Critically ill patients requiring prolonged intensive care (ICU) treatment are at high risk of malnutrition, which latter contributes to worsening outcome. Having observed that despite the presence of a nutrition protocol and dieticians, the patients with persistent critical illness (PCI) had been underfed during their ICU stay and particularly during the first 10 days, the aim was to analyse the impact of the organisational changes that were proposed to prevent the observed malnutrition. METHODS: Before (Period A) and after (Period B) study enrolling critically ill patients consecutively admitted, requiring >10 days of ICU treatment. The intervention consisted in increasing the early morning interactions between dieticians, nurses, and physicians, while modifying the computer visualisation of the dietician proposals. The primary endpoint was a reduction in the cumulative energy balance in period B. The ICU stay was divided in early ICU stay (first 10 days) and late ICU stay (day 11 to day 30). Other variables: protein, glucose, and prealbumin. RESULTS: Altogether, 205 patients (150 and 55 in period A and B respectively) were enrolled in the PCI program. Patient characteristics were similar over both periods except for lower SAPSII score in period B. There was no difference in nutritional pattern in the first 10 days between periods. The cumulate energy balance was less negative from day 11-30 in period B than in A (-884 vs -1566 kcal; p = 0.033). There was a one-day reduction in the median duration of fasting in period B (p < 0.0001). Overall compliance with nutrition protocol improved in period B with an earlier first indirect calorimetry (p = 0.003) and prealbumin measurement (p < 0.001), the latter increasing significantly more during ICU stay. CONCLUSION: Organizational changes that allowed an early identification of patients at nutritional risk, an increased targeted dieticians intervention and a better inter-disciplinary work was associated with a reduction in undue fasting, and significantly improved energy balances.

Video fluoroscopy for pulmonary artery catheter insertion in high-risk situation of knotting or misplacement.

Pulmonary artery catheter (PAC) insertion in patients with severe pulmonary hypertension, right heart dilation and failure, is very challenging. Misplacement and knotting are rare but could be serious complications leading to a delay of the monitoring and sometimes an emergent not expected intervention. Here we report a case of a patient admitted to Intensive Care Unit (ICU) with an acute hypoxemic respiratory failure. She had a history of chronic respiratory failure with pulmonary hypertension and right heart failure. We decided to monitor her cardiac output and pulmonary pressure with a PAC. Repeated attempts to reach the pulmonary artery (PA) were unsuccessful and the PAC was knotted and blocked at the distal tip of the introducer. Under fluoroscopy the knot was released by radiologist. Few days later, a monitoring of PA pressure was needed to guide a PA vasodilator treatment. Under fluoroscopic guidance with the supervision of radiologist, the catheter was successfully placed in the PA at the first attempt. Despite some limitations (patient displacement and radiation), this technique is more accurate than waveform guidance. We suggest in specific situations (low cardiac output, severe pulmonary hypertension, and severe tricuspid regurgitation) to consider first fluoroscopy.

Antibiotic use: is appropriateness expensive?

Antibiotics are prone to misuse. In this study, 37% of 600 antibiotic prescriptions in three hospitals were considered unnecessary. When antibiotic therapy was indicated, 45% were considered to be inadequate. In multivariate analyses, the indicated treatments were found to be more expensive than the unjustified ones, probably because the latter were more often oral regimens. However, for indicated treatments, the cost of adequate and inadequate treatments did not differ significantly.

[Are hospital network interesting for intensive care medicine?]. / Réseaux hospitaliers: quel intérêt en médecine intensive?

In critical care medicine, collaborative networks are well-developped for clinical research. This model is equally interesting for care, education and management. For example, in a network, an intensivist can be easily sent to another hospital in order to deliver specialized care. In French and Italian part of Switzerland, a critical care network was recently founded and it implements now several collaborative projects. Networks are very interesting for their members because they allows some small ICUs to survive and avoid very expensive costs related to restructuration of the larger ones. Thus, this model will certainly develop during the next years.

[Latin program for organ donation: the intensivists are networking]. / Programme latin de don d'organes: les intensivistes se mettent en réseau.

The new Swiss federal law on organ and transplantation strengthens the responsibilities of the intensive care units. In Italian and French speaking parts of Switzerland, the Programme Latin pour le Don d'Organe (PLDO) has been launched to foster a wider collaboration between intensivists and donation coordinators. The PLDO aims at optimising knowledge and expertise in organ donation through improvements in identification, notification and management of organ donors and their next of kin. The PLDO dispenses education to all professionals involved. Such organisation should allow increasing the number of organs available, while improving healthcare professionals experience and next of kin emotion throughout the donation process.

[Merging of two intensive care units: preliminary observations]. / Fusion de deux services de médecine intensive: quelques observations préliminaires.

The merging of two intensive care units is a time of profound change, and constitutes a risk of mishaps. We report some aspects of such a project in our institution. The evaluation of various indicators reflecting the activity, patient's hospital pathways, mortality, as well as the use of specific techniques, has shown that no particular problem was observed during the first 9 months. Improvements in performance or productivity have not been demonstrated so far. The follow-up will permit to demonstrate long-term benefits. We believe that these observations may be of interest for other departmental or hospital reorganisations.

Multiple symmetric lipomatosis: abnormalities in complex IV and multiple deletions in mitochondrial DNA.

Multiple symmetric lipomatosis (MSL) is a rare disorder of middle life characterized by large nonencapsulated lipomas distributed around the neck, shoulders, and other axial regions. Neurologic involvement, particularly peripheral neuropathy, is frequent. The pathogenesis of the syndrome is still unknown, but ragged-red fibers are occasionally present in muscle of affected patients, suggesting a mitochondrial abnormality. We studied 11 unrelated patients with MSL by means of neurophysiology, muscle morphology, muscle biochemistry, Southern blot, and PCR analysis of mitochondrial DNA. All patients were men aged 41 to 63 years. Clinical or electrophysiologic signs of a sensorimotor polyneuropathy were present in nine patients, eight of whom had a history of alcoholism. In muscle biopsy specimens, the most prominent feature was pathologic subsarcolemmal aggregates of mitochondria. Biochemical analysis of respiratory chain enzymes revealed a moderate but significant decrease of cytochrome c oxidase activity as compared with age-matched controls. In one patient, Southern blot analysis showed multiple deletions of mitochondrial DNA. We conclude that mitochondrial dysfunction is common in MSL and may be based on identifiable defects in the mitochondrial genome.

Bone densitometry of the forearm: comparison of single-photon and dual-energy X-ray absorptiometry.

Forearm bone mineral densitometry was performed initially by single-photon absorptiometry (SPA), but is now achievable by dual-energy X-ray absorptiometry (DXA) as well, with a good correlation between both measurements. However, it is still unknown whether: (1) short-term precision of DXA is superior to SPA and (2) identical regions of interest (ROI) are mandatory to correlate SPA with DXA. The aim of this study was to answer these questions using a commercial system for DXA (DXA-FAS) and to test an in-house system using spine DXA and a soft-tissue compensator (DXA-STC). In ten subjects, four measurements on the same day showed significantly lower (p < 0.05) coefficients of variation (CV) for bone mineral density (BMD) by DXA-FAS (proximal site: 0.74%; ultradistal site: 1.20%) than by SPA (1.26% and 2.25%). However, the CV for bone mineral content (BMC) were similar for DXA-FAS (0.73% and 1.58%) and SPA (0.79% and 1.34%). The significant difference (p < 0.05) for surface calculation by DXA-FAS (1.24% and 0.93%) compared with SPA (2.36% and 1.28%) explains all the advantages of DXA-FAS for short-term precision. The measurements taken on the same day on the ulna and the radius or on the radius alone by SPA, DXA-FAS, and DXA-STC on 108 subjects aged 18-80 years were highly correlated [r ranging from 0.925 to 0.995 (p < 0.0001) and standard error of the estimate from 3.15% to 8.89%]. The need for a manual adjustment of the ROI was found to be mandatory for BMC but not BMD assessment. The use of DXA-STC is a fast method for forearm bone densitometry and its correlation with SPA is very high. However, its short-term precision for BMC (3.00% and 1.54%), BMD (2.15% and 1.12%), and surfaces (1.99% and 1.12%) is significantly higher (p < 0.05) than that of DXA-FAS. We conclude that short-term precision of DXA is better than that of SPA only for BMD and surface measurement but not for BMC. ROI should be adjusted manually for the assessment of BMC but not for that of BMD.

Tissue oxygenation and hemodynamic response to NO synthase inhibition in septic shock.

The objective of the study was to evaluate the tissue oxygenation and hemodynamic effects of NOS inhibition in clinical severe septic shock. Eight patients with septic shock refractory to volume loading and high level of adrenergic support were prospectively enrolled in the study. Increasing doses of NOS inhibitors [N(G)-nitro-L-arginine-methyl ester (L-NAME) or N(G)-monomethyl-L-arginine (L-NMMA)] were administered as i.v. bolus until a peak effect = 10 mmHg on mean blood pressure was obtained or until side effects occurred. If deemed clinically appropriate, a continuous infusion of L-NAME was instituted and adrenergic support weaning attempted. The bolus administration of NOS inhibitors transiently increased mean blood pressure by 10 mm Hg in all patients. Seven out of eight patients received an L-NAME infusion, associated over 24 h with a progressive decline in cardiac index (P < 0.001) and an increase in systemic vascular resistance (P < 0.01). Partial or total adrenergic support weaning was rapidly possible in 6/8 patients. Oxygen transport decreased (P < 0.001), but oxygen consumption remained unchanged in those patients in whom it could be measured by indirect calorimetry (5/8). Blood lactate and the difference between tonometric gastric and arterial PCO2 remained unchanged. There were 4/8 ICU survivors. We conclude that nitric oxide synthase inhibition in severe septic shock was followed with a progressive correction of the vasoplegic hemodynamic disturbances with finally normalization of cardiac output and systemic vascular resistances without any demonstrable deterioration in tissue oxygenation.

Pharmacokinetics and dosage adaptation of meropenem during continuous venovenous hemodiafiltration in critically ill patients.

Meropenem, a carbapenem broad-spectrum antibiotic, is regularly used in patients undergoing continuous venovenous hemodiafiltration (CVVHDF). Its disposition was studied over one dosage interval in 15 patients under CVVHDF on a steady regimen of 500 or 1000 mg every 8 to 12 hours. Meropenem levels were measured in plasma and filtrate-dialysate by high-performance liquid chromatography (HPLC) with UV detection. The mean CVVHDF flow rates were 7.1 +/- 0.9 L/h for blood (mean +/- SD), 0.5 +/- 0.3 L/h for predilution solution, 1.2 +/- 0.3 L/h for countercurrent dialysate, and 1.8 +/- 0.5 L/h for the total filtrate-dialysate. The pharmacokinetic analysis was based both on a noncompartmental approach and on a four-compartment modeling. The mean (coefficient of variation [CV]) total body clearance, volume of distribution at steady state, and mean residence time were, respectively, 5.0 L/h (46%), 14.3 L (29%), and 4.8 h (36%). The hemodiafiltration clearances calculated from plasma data alone and plasma with filtrate-dialysate data were 1.2 L/h (26%) and 1.6 L/h (39%), respectively. The compartmental model was used to optimize the therapeutic schedule of meropenem, considering reference minimal inhibitory concentration (MIC) of sensitive strains (4 mg/L). The results indicate that two different therapeutic schedules of meropenem are equally applicable to patients receiving CVVHD: either 750 mg tid or 1500 bid.

Comparison of models used for UV index calculations.

Eighteen radiative transfer models in use for calculation of UV index are compared with respect to their results for more that 100 cloud-free atmospheres, which describe present, possible future and extreme conditions. The comparison includes six multiple-scattering spectral models, eight fast spectral models and four empirical models. Averages of the results of the six participating multiple-scattering spectral models are taken as a basis for assessment. The agreement among the multiple-scattering models is within +/- 0.5 UV index values for more than 80% of chosen atmospheric parameters. The fast spectral models have very different agreement, between +/- 1 and up to 12 UV index values. The results of the empirical models agree reasonably well with the reference models but only for the atmospheres for which they have been developed. The data to describe the atmospheric conditions, which are used for the comparison, together with the individual results of all participating models and model descriptions are available on the Internet: http://www.meteo.physik.uni-muenchen.de/++ +strahlung/cost/.

Malignant tumors of the anus. A study of 106 cases.

This study of 106 cases of malignant tumors of the anus has shown that the diagnosis was often made late. In 15 percent of the patients the tumor was at the anal margin; in 61 percent, in the anal canal, and in 24 percent, the tumor was so extensive that its origin could not be determined clinically. In nearly half of the cases, the cancers were advanced and showed perirectal metastases. Surgical treatment was the rule, with local excision for carcinomas of the anal margin and abdominoperineal resection for tumors of the canal. The general prognosis over a period of several decades remains poor. We found a 20 percent 5 year survival rate for epidermoid carcinoma of the anal canal, excluding deaths from causes other than cancer during the follow-up period.

Incidental splenectomy: early and late postoperative complications.

Of 542 splenectomies performed from 1964 to 1977, 242 were incidental to gastrointestinal surgery. The highest rate of complications was observed in these patients as opposed to those who underwent splenectomy for trauma or Hodgkin's disease. Eighteen laboratory studies did not show significant changes 1.5 to 10 years postoperatively in 96 patients. Ninety-three patients questioned because of late symptoms had the highest rate of complaints after incidental splenectomy.

Exposure to toluenediamines from polyurethane-covered breast implants.

Toluenediamines (TDA) were monitored in blood, urine and redon drainage following implantation of polyurethane (PU)-covered breast prostheses. In the redon drainage TDAs showed an initial steep drop. The levels did not fall below detection limits but formed a plateau, which suggests a continued degradation of the PU foam. Urinary metabolite levels were above pre-operation background in all samples collected. In plasma there is an initial lag period of 20-30 days, where little above background TDA was found, after which levels rose to above 4.0 and 1.5 ng/ml plasma for 2,4-toluenediamine (24TDA) and 2,6-toluenediamine (26TDA), respectively. Elevated levels were found up to 2 years post-operation. Acid hydrolysis of precipitated plasma proteins released equivalent amounts of TDA as from total plasma, TDA being covalently bound to both albumin and globulin fractions. Urinary and plasma levels from these patients are in the same range detected from occupational exposure to toluene diisocyanate.

[Radiological and clinical aspects of resection of the cardia]. / Radiologische und klinische Aspekte nach Kardiaresektion

Following resection of the cardia, problems may arise during two phases; in these, clinical and radiological examination may be required. Immediately after the operation one is concerned particularly with checking the incision or the extent and localisation of suture abnormalities. In the late post-operative period the problems are different. In addition to a description of the anatomy at the proximal and distal ends of the stomach, it is necessary to estimate functional conditions, such as passage through the anastomosis and the pylorus, the reservoir function of the gastric remnant and gastro-oesophageal reflux. An important task is to demonstrate tumour recurrence. For this purpose endoscopic, biopsy and cytological examinations are required.

[Splenic artery ligature and latero-lateral anastomosis in portal hypertension (author's transl)]. / Milzarterienligatur und laterolaterale splenorenale Anastomose bei der portalen Hypertension

A new type of shunt for decompressing portal hypertension is described, consisting of ligation of the spleno-renal anastomosis. This reduces the pressure in the portal territory and in the dangerous gastric and oesophageal varices. In addition the procedure also abolishes the marrow inhibition due to splenic activity without removing the spleen and maintaining part of the portal circulation. The advantages and disadvantages of various decompression operations are discussed and compared with other methods in current use.