Home enteral feeding: analysis and improvement of organizational models.

AIM: The purpose of this study was to analyze the organizational models of home enteral feeding used in 5 local health authorities (LHAs) in the Veneto region (Italy). By comparing these models with the main guidelines, the authors have attempted to determine the "minimum standards" to be adopted at an organizational level. MATERIALS AND METHODS: This 3-stage study analyzes procedures, precoded actions, and recordable processes. Stage 1: objectives were defined, work methods selected, and reference guidelines chosen. Stage 2: flowcharts were drafted to show the actions and work paths taken for the 5 LHAs. Stage 3: flowcharts were compared with data from the literature. RESULTS: The study shows that very different organizational models exist. For instance, by comparing organizational processes with the procedures prescribed by the guidelines, it can be seen that the mean percentages of actions taken by the 5 LHAs, for patients in both rest homes and nursing homes, rarely exceeds the threshold of 50% (on a scale from 0% to 100%). CONCLUSION: This study shows that home enteral feeding is neither optimized nor uniform in the 5 LHAs and that standardized methods are not used for clinical monitoring.

Clinical governance benchmarking issues in oncology: aggressiveness of cancer care and consumption of strong opioids. A single-center experience on measurement of quality of care.

AIMS AND BACKGROUND: The aggressiveness of cancer care near the end of life and the consumption of opioids are potential indicators of quality of care in palliative and end-of-life settings. The purpose of this article is to present a retrospective analysis regarding these themes and the adopted procedures to improve quality of care. METHODS: We evaluated all cancer patients treated and deceased during 2008 and considered those who died and received any antiblastic therapy within 14 and 30 days prior to death. Moreover, we evaluated the annual consumption of pure opioids during 2007 and 2008 in our inpatient clinic. We found that 5% and 9% of all treated patients were still receiving antiblastic treatment near the end of life within respectively 14 and 30 days prior to death (respectively 29.6% and 51.5% of deceased patients). All but 2 patients died from progressive disease, one patient died from acute myocardial infarction during chemotherapy, and one of severe sepsis after chemotherapy for non-Hodgkin lymphoma. As regards the annual consumption of strong opioids, there was a 179% increase in the use of morphine-equivalent doses of oral long-acting opioids (+228% for oxycodone) after the introduction of daily pain measurement through a numerical rating scale. CONCLUSIONS: To reduce the administration of chemotherapy near the end of life, we introduced the palliative prognostic score, to be administered to all advanced cancer patients with performance status of at least 2. To evaluate the effectiveness of analgesics and to reduce the cases of undertreatment of cancer pain, we adopted, in addition to the numerical rating scale, Cleeland's Pain Management Index. We are convinced that attempts to improve the quality of care can be achieved by the collaboration of all health professionals, patients and care givers.

Ifosfamide encephalopathy and use of methylene blue. A case report of different sequential neurotoxicity.

Neurotoxicity is a clinically relevant adverse event observed with the use of ifosfamide. It is usually mild, occasionally severe and seldom fatal. Ifosfamide-induced encephalopathy requires interruption of chemotherapy, intravenous hydration and administration of methylene blue. Less is known about the efficacy of methylene blue in avoiding a second episode of ifosfamide-induced encephalopathy while maintaining chemotherapy with ifosfamide. We report a case of a different clinical manifestation of ifosfamide-induced encephalopathy after continued ifosfamide use and despite methylene blue in a patient with retroperitoneal sarcoma.