Accreditation of nutrition support teams: A new initiative by the Turkish Society of Clinical Enteral & Parenteral Nutrition.

OBJECTIVES: Accreditation is a process to evaluate compliance of an institution or organization with predetermined performance standards, focusing on achieving continuous improvement strategies and optimal quality standards and motivating the accredited organization to do so. There is no established accreditation program for nutrition support teams (NSTs) at national and international levels. In order to increase the standards of NSTs, developing an accreditation program is being planned by the Turkish Society of Clinical Enteral & Parenteral Nutrition (KEPAN). METHODS: Accreditation standards were developed by a study group under the organization of KEPAN. Minimum standards for composition, qualifications, physical requirements, workflow charts, medical records, and both patient and health care providers' safety measures in NSTs were specified. These standards were uploaded to a computer program, and the necessary infrastructure for a web-based management of accreditation processes was developed. RESULTS: An organization applying for accreditation should fill in the application form on KEPAN website electronically. Eligibility criteria for accreditation include number of NST members, physical environment, patient monitoring requirements, research, and training. A total of 22 standards are surveyed under 13 sections. These standards contain 61 criteria. To be accredited, each of 22 standards must score >70 and each of 13 sections must score >80. CONCLUSIONS: In order to increase the quality of nutritional care and improve patient outcomes, an accreditation program has been developed. This program principally sets the basic standards, organizational scheme, and responsibilities of NSTs.

Evaluation of the effect of antibiotics used during parenteral nutrition treatment on Candidemia

SUMMARY OBJECTIVE: Parenteral nutrition is an important risk factor for candidemia. In this risk analysis study, the effect of previous antibiotic administration apart from the length of hospital stay, duration of Parenteral nutrition treatment, and Candida score parameters on developing candidemia was evaluated in the non-neutropenic patients receiving Parenteral nutrition treatment. METHODS: In this double center, retrospective, and cross-sectional study, the data of patients who received Parenteral nutrition treatment were collected. Patients with or without candidemia after the initiation of Parenteral nutrition treatment were compared in terms of demographic features, Candida score, length of hospital stay, duration of Parenteral nutrition treatment, and previous use of antibiotics. Then, predictor factors affecting the probability of candidemia during Candida growth time were determined by the Cox regression analysis. RESULTS: A total of 148 patients (59.5% males) were included and 16 (10.81%) of these had candidemia after initiation of parenteral nutrition treatment. The median (min-max) duration of parenteral nutrition treatment was 11 (4-72) days and the Candida growth time was 13 (7-29) days. Statistically significant differences were found between patients with or without candidemia groups in terms of length of hospital stay (p<0.001), duration of parenteral nutrition treatment (p<0.001), and Candida score (p<0.001). To determine the effect of these variables and antibiotics on candidemia, length of hospital stay [Hazard Ratio 1.030; p=0.021] and piperacillin-tazobactam (Hazard Ratio 5.626; p=0.030) were found significant and independent risk factors on the development of candidemia. CONCLUSION: There are some well-known risk factors including length of hospital stay, duration of Parenteral nutrition treatment, and Candida score; the potential impact of piperacillin-tazobactam administration should also be considered since they may be effective on the development of candidemia.

Evaluation of the effect of antibiotics used during parenteral nutrition treatment on Candidemia.

OBJECTIVE: Parenteral nutrition is an important risk factor for candidemia. In this risk analysis study, the effect of previous antibiotic administration apart from the length of hospital stay, duration of Parenteral nutrition treatment, and Candida score parameters on developing candidemia was evaluated in the non-neutropenic patients receiving Parenteral nutrition treatment. METHODS: In this double center, retrospective, and cross-sectional study, the data of patients who received Parenteral nutrition treatment were collected. Patients with or without candidemia after the initiation of Parenteral nutrition treatment were compared in terms of demographic features, Candida score, length of hospital stay, duration of Parenteral nutrition treatment, and previous use of antibiotics. Then, predictor factors affecting the probability of candidemia during Candida growth time were determined by the Cox regression analysis. RESULTS: A total of 148 patients (59.5% males) were included and 16 (10.81%) of these had candidemia after initiation of parenteral nutrition treatment. The median (min-max) duration of parenteral nutrition treatment was 11 (4-72) days and the Candida growth time was 13 (7-29) days. Statistically significant differences were found between patients with or without candidemia groups in terms of length of hospital stay (p<0.001), duration of parenteral nutrition treatment (p<0.001), and Candida score (p<0.001). To determine the effect of these variables and antibiotics on candidemia, length of hospital stay [Hazard Ratio 1.030; p=0.021] and piperacillin-tazobactam (Hazard Ratio 5.626; p=0.030) were found significant and independent risk factors on the development of candidemia. CONCLUSION: There are some well-known risk factors including length of hospital stay, duration of Parenteral nutrition treatment, and Candida score; the potential impact of piperacillin-tazobactam administration should also be considered since they may be effective on the development of candidemia.

Construction Project Safety Performance Management Using Analytic Network Process (ANP) as a Multicriteria Decision-Making (MCDM) Tool.

The paper addresses the context in which the construction industry is considered risky, as the intense labor and machine environment interacts with acceleration and overlapping activities. This situation results in accidents and fatalities. A high number of accidents and fatalities leads to additional costs and delays, detrimental to all stakeholders. Hazard identification and quantification of their impacts on building safety are crucial for planning. Classifying security risks is a complex process, and risks are interconnected. There is a gap in the literature to study the interconnections of these hazards along with the frequency of occurrences. To bridge this gap, the frequency-adjusted importance index and the ANP (Analytical Networking Process) tool were used to capture the 14 interconnections and their frequencies based on the results of a survey distributed to 106 construction professionals. The main contribution of this work to existing knowledge is to identify and prioritize potential risks in the construction sector, considering their interconnections and their level of occurrence frequency. This is the first study in the literature to combine the frequency-adjusted importance index and the ANP tool, both integrated. The results from the importance index was used as the base for pairwise comparison for the ANP model. Based on the results from the model, recommendations to industry professionals are provided and presented.

Healthcare expenditure and carbon footprint in the USA: evidence from hidden cointegration approach.

The priority aim of this study is to investigate the effect of carbon footprint, which is an indicator of environmental degradation, on health expenditures for the USA. In the study, cointegration analysis was performed for the period 1970-2016 by using health expenditures, carbon footprint, gross domestic product per capita and life expectancy at birth variables. According to the results of standard cointegration analysis, only cointegration relationship between health expenditures and income was found. In the models with carbon footprint, no cointegration relationship was discovered between the original values of the variables. This result was approached with suspicion, and it was thought that there might be a hidden cointegration between healthcare expenditures and carbon footprint. For this purpose, the hidden cointegration analysis and crouching error correction model proposed by Granger and Yoon [18] were employed among the positive and negative components of the variables of healthcare expenditures and carbon footprint. The results of the hidden cointegration analysis revealed that there was a hidden cointegration relationship between the positive components of healthcare expenditures and the positive components of carbon footprint. Analysis results show that a 1% increase in carbon footprint will cause a 2.04% increase in healthcare expenditures in the long term in the USA. When the positive components of the variables were considered, it was concluded that there was a one-way long-term asymmetric causality relationship between carbon footprint and healthcare expenditures. As a result of the study, it was proposed that the carbon footprint should be diminished to prevent the increasing burden of the healthcare expenditures on the budget.

Non-Invasive Mechanical Ventilation in Critically Ill Trauma Patients: A Systematic Review.

There is limited literature on non-invasive mechanical ventilation (NIMV) in patients with polytrauma-related acute respiratory failure (ARF). Despite an increasing worldwide application, there is still scarce evidence of significant NIMV benefits in this specific setting, and no clear recommendations are provided. We performed a systematic review, and a search of clinical databases including MEDLINE and EMBASE was conducted from the beginning of 1990 until today. Although the benefits in reducing the intubation rate, morbidity and mortality are unclear, NIMV may be useful and does not appear to be associated with harm when applied in properly selected patients with moderate ARF at an earlier stage of injury by experienced teams and in appropriate settings under strict monitoring. In the presence of these criteria, NIMV is worth attempting, but only if endotracheal intubation is promptly available because non-responders to NIMV are burdened by an increased mortality when intubation is delayed.

A 10-step safety management framework for construction small and medium-sized enterprises.

It is of great importance to develop an occupational health and safety management system (OHS MS) to form a systemized approach to improve health and safety. It is a known fact that thousands of accidents and injuries occur in the construction industry. Most of these accidents occur in small and medium-sized enterprises (SMEs). This article provides a 10-step user-friendly OHS MS for the construction industry. A quantitative OHS MS indexing method is also introduced in the article. The practical application of the system to real SMEs and its promising results are also presented.

RAPID FLUID ADMINISTRATION AND THE INCIDENCE OF HYPOTENSION INDUCED BY SPINAL ANESTHESIA AND EPHEDRINE REQUIREMENT: THE EFFECT OF CRYSTALLOID VERSUS COLLOID COLOADING.

PURPOSE: Spinal anesthesia for caesarean delivery is often associated with hypotension. This study was conducted to evaluate the effects of rapid crystalloid (Lactated Ringer's solution; LRS) or colloid (hydroxyethyl starch; HES) cohydration with a second intravenous access line on the incidence of hypotension and ephedrine requirement during spinal anesthesia for cesarean section. METHODS: We studied 90 women with uncomplicated pregnancies undergoing elective cesarean section under spinal anesthesia. Intravenous access was established in all patients with two peripheral intravenous lines, the first being used for the baseline volume infusion. Immediately after induction of spinal anesthesia, LRS (Group L) or HES (Group C) infusions were started at the maximal possible rate via the second line in groups L and C respectively. In the third group (Group E), patients received lactated Ringer's solution at a 'keep vein open' rate to maintain the double-blind nature. The incidence of hypotension, ephedrine requirements, total amount of volume and side effects were recorded. RESULTS: The incidence of hypotension was significantly greater in group E than in groups L and C, and greater in group L than in group C (p < 0.03 and p < 0.01 respectively ). The total dose of ephedrine used to treat hypotension was significantly less in groups L and C than in group E (p < 0.001 and p < 0.001 respectively). Groups L and C received similar infusion volumes and doses of ephedrine. CONCLUSIONS: Giving either LR or HES coloading via a second IV line caused less hypotension and required less use of ephedrine compared to no coloading. There were no maternal or neonatal side effects.

A Comparative Study of the Efficacy of IV Dexketoprofen, Lornoxicam, and Diclophenac Sodium on Postoperative Analgesia and Tramadol Consumption in Patients Receiving Patient-Controlled Tramadol.

OBJECTIVE: This study was designed to compare the effects of dexketoprofen, lornoxicam, and diclophenac sodium on postoperative analgesia and tramadol consumption in patients receiving postoperative patient-controlled tramadol after a major abdominal surgery. METHODS: Eighty patients were randomized to receive one of the four study drugs. Patients in group dexketoprofen (DT) received IV 50 mg dexketoprofen, group lornoxicam (LR) received IV 8 mg lornoxicam, group diclophenac sodium (DS) received 75 mg IV diclophenac sodium and group saline (S) received 0.9% saline in 2 mL syringes, 20 min before the end of anaesthesia. A standardized (1 mg kg(-1)) dose of tramadol was routinely administered to all patients as the loading dose at the end of surgery. Postoperatively, whenever patients requested, they were allowed to use a tramadol patient-controlled analgesia device giving a bolus dose (0.2 mg kg(-1)) of tramadol. Pain, discomfort, and sedation scores, cumulative tramadol consumption, supplemental meperidine requirement, and side effects were recorded. RESULTS: Visual rating scale and patient discomfort scores were significantly lower in DT, LR and DS groups compared to those in in group S (p<0.001). Cumulative tramadol consumption was significantly lower in non-steroidal anti-inflammatory drug (NSAID)-treated groups at each study period after the second postoperative hour than in group S (p<0.001). Supplemental meperidine requirement was significantly higher in group S at each study period after postoperative 30 min than in NSAID-treated groups (p<0.01). CONCLUSION: After major abdominal surgery, adding IV diclophenac, lornoxicam or dexketoprofen to patient-controlled tramadol resulted in lower pain scores, smaller tramadol consumption, less rescue supplemental analgesic requirement, and fewer side effects compared with the tramadol alone group.

Safety risk assessment using analytic hierarchy process (AHP) during planning and budgeting of construction projects.

INTRODUCTION: The inherent and unique risks on construction projects quite often present key challenges to contractors. Health and safety risks are among the most significant risks in construction projects since the construction industry is characterized by a relatively high injury and death rate compared to other industries. In construction project management, safety risk assessment is an important step toward identifying potential hazards and evaluating the risks associated with the hazards. Adequate prioritization of safety risks during risk assessment is crucial for planning, budgeting, and management of safety related risks. METHOD: In this paper, a safety risk assessment framework is presented based on the theory of cost of safety (COS) model and the analytic hierarchy process (AHP). The main contribution of the proposed framework is that it presents a robust method for prioritization of safety risks in construction projects to create a rational budget and to set realistic goals without compromising safety. THE IMPACT TO THE INDUSTRY: The framework provides a decision tool for the decision makers to determine the adequate accident/injury prevention investments while considering the funding limits. The proposed safety risk framework is illustrated using a real-life construction project and the advantages and limitations of the framework are discussed.

Corruption and internal fraud in the Turkish construction industry.

The purpose of this paper is to develop an understanding about the internal fraud and corruption problem in the Turkish construction industry. The reasons behind the internal fraud and corruption problem as well as the types of prevention methods were investigated; and as a result various recommendations were made. To this end, a risk awareness questionnaire was used to understand the behavioral patterns of the construction industry, and to clarify possible proactive and reactive measures against internal fraud and corruption. The type of fraud experienced by Turkish construction companies was also surveyed in the questionnaire. The questionnaire was sent to 89 firms; and depending on the collected data, certain recommendations for construction industry professionals were provided.

A comparative study on the effects of intrathecal morphine added to levobupivacaine for spinal anesthesia.

OBJECTIVE: In this prospective, randomized, double-blind, controlled study, we investigated the sensory, motor, and analgesic block characteristics oftwo diferent doses of morphine compared with saline when added to 0.5 percent levobupivacaine. DESIGN: Prospective, randomized, double-blinded, controlled study. SETTING: University hospital. PATIENTS, PARTICIPANTS, INTERVENTIONS: One hundred and twelve ASA I or II adult patients undergoing cesarean section with combined-spinal epidural anesthesia (CSEA) were randomly allocated to receive 0.5 mL of0.9 percent sodium chloride in group S, 0.1 mg of morphine in group M1, or 0.2 mg of morphine in group M2 following 15 mg of isobaric spinal levobupivacaine 0.5 percent (3 mi). MAIN OUTCOME MEASURE(S): We recorded the following: onset and duration of sensory and motor block, duration of spinal anesthesia, time to first request for analgesia, and side effects. RESULTS: The onset time ofsensory block was significantly less in group M2 (3.5 + 3 minutes) than S (4 +/- 3 minutes; p < 0.003). Parturientsgiven morphine had a significantly greater duration of analgesia (554 +/- 350 minutes in group M1 and 879 -725 minutes in group M2) than the saline group (80 +/- 70 minutes; p < 0.001). Similarly, the time to first request for analgesia was longer in groups M1 (582 +/- 470 minutes) and M2 (917+/- 709 minutes) than in group S (92 +/- 77 minutes; p < 0.001). CONCLUSION: In patients undergoing cesarean delivery with CSEA, adding intrathecal morphine (0.1 and 0.2 mg) to 15 mg of spinal levobupivacaine prolonged the duration of spinal analgesia and provided rapid onset of action and longer time to first analgesic request without causing any significant side effect compared to saline.

Comparison of effects of ketamine, ketamine-dexmedetomidine and ketamine-midazolam on dressing changes of burn patients.

OBJECTIVE: The aim of this randomized, controlled study was to compare the sedoanalgesic effects of ketamine-dexmedetomidine and ketamine-midazolam on dressing changes of burn patients. MATERIALS AND METHODS: Following Ethics Committee approval and informed patient consent, 90 ASA physical statuses I and II adult burn patients were included in the study. Patients were randomly divided into three groups. Ten minutes before dressing change, the dexmedetomidine group (group KD) (n = 30) received a continuous infusion of dexmedetomidine at a rate of 1 µg kg(-1), the midazolam group (group KM) (n = 30) received a continuous infusion of midazolam at a rate of 0.05 mg kg(-1) and the saline group (group KS) (n = 30) received a continuous infusion of saline intravenously. One minute before dressing change, each patient was administered 1 mg kg(-1) ketamine intravenously. Hemodynamic variables, pain and sedation scores, the number of patients requiring additional ketamine, time to dressing change and recovery time were recorded. RESULTS: Systolic blood pressure (SBP) values were significantly lower at, before and after ketamine administration; and 5, 10 and 15 minutes after the procedure in group KD in comparison with the other groups (P <0.05). There was no significant difference in pain scores among the groups during the study period. Sedation scores were significantly higher in group KD than in groups KM and KS at the end of the first hour (P <0.05). Time to dressing change and recovery time were similar in all the groups CONCLUSION: In burn patients undergoing dressing changes, although both combinations ketamine-dexmedetomidine and ketamine-midazolam offered an effective sedoanalgesia without causing any significant side effect, the former resulted in higher sedation and lower hemodynamic discrepancy.

[Effect of ondansetron in lower extremity bone surgery on morphine and tramadol consumption using patient controlled analgesia]. / Alt ekstremite kemik cerrahisinde hasta kontrollü analjezide ondansetronun tramadol ve morfin tüketimine etkisi.

In this study, we aimed to assess the effect of administration of ondansetron on morphine and tramadol consumptions. After approval by the ethics committee, 120 patients with ASA status I or II, who will undergo elective lower extremity surgery, were included in the study. Patients were randomly divided into 4 groups following the anesthesia induction. Group I received tramadol as PCA with an infusion of 0.3 mg/kg following a loading dose of 1.5 mg/kg administered 1 hour before the end of the surgery. Group II received ondansetron 0.1 mg/kg following induction of anesthesia, additionally. Group III received morphine as PCA with an infusion following a loading dose of 0.15 mg/kg administered 30 minutes before the end of surgery. Group IV received ondansetron 0.1 mg/kg following induction of anesthesia, additionally. Pain scores(VAS), nausea, vomitting and sedation scores, analgesic consumptions and adverse effects were recorded at 5th, 15th, 30th, 45th minutes and 4th, 8th, 12th and 24th hours postoperatively. Postoperative VAS, nausea, vomitting and sedation scores were similar among the groups. The analgesic consumption was found significantly higher at 4th, 8th, 12th and 24th hours in group II. No statistically significant difference was found in analgesic consumption between group III and IV at all times. We concluded that, ondansetron, when administered as nausea prophylaxis in patients receiving tramadol and morphine as PCA, did not effect morphine consumption whereas did increased tramadol consumption.

Dexmedetomidine versus midazolam in outpatient third molar surgery.

PURPOSE: The aim of this study was to compare the use of dexmedetomidine with the use of midazolam during intravenous conscious sedation in third molar surgery. PATIENTS AND METHODS: Twenty healthy patients with symmetrically impacted mandibular third molars were included in this double-blind, crossover, randomized study. Either dexmedetomidine (group D) (4 microg.kg(-1).h(-1)) or midazolam (group M) (0.4 mg.kg(-1).h(-1)) was administered intravenously for 15 minutes before the first operation. At the second operation, the other agent was applied. Cardiorespiratory data were collected. The intraoperative sedation level, patient cooperation, and postoperative performance were scored and any pain reaction during the local anesthetic injection was recorded. Visual analog scales were additionally used for the subjective assessment of pain and patient satisfaction. Amnesia was evaluated by the patients' ability to recall the objects shown during the operations and the local anesthetic injection. Patients' preferences were recorded during the interview at the end of the second operations. RESULTS: The mean heart rate and blood pressure measurements were significantly lower in group D. There was no significant difference in the respiratory findings. A significantly higher number of patients showed pain reactions in group M. Sedation level, postoperative performance, and VAS pain scores were not statistically significant, whereas the differences in cooperation score and VAS for patient satisfaction were significant. Adequate amnesia was obtained in group M, however, no amnesia was demonstrated in group D. Sixty-five percent of the patients indicated a preference for dexmedetomidine sedation. CONCLUSION: Dexmedetomidine may be a remarkable alternative to midazolam for intravenous sedation because it seems to be a reliable and safe method, with additional analgesic effect providing a satisfactory sedation level without any serious side effects during impacted third molar surgery.

Comparison of caudal vs intravenous tramadol administered either preoperatively or postoperatively for pain relief in boys.

BACKGROUND: In this study we compared caudal with intravenous (i.v.) tramadol given pre- or postoperatively for pain relief in boys having hypospadias repair. METHODS: The study was approved by the Ethics Committee and informed written consent was obtained from the parents of each patient. Patients (n = 134), aged 1-3 years, American Society of Anesthesiologists (ASA) physical status I, scheduled for hypospadias surgery were recruited. The patients were randomly allocated to one of the four groups: group I (n = 33), received 2 mg.kg(-1) (0.5 ml.kg(-1)) of caudal tramadol after the surgical procedure was completed, group II (n = 33) received 2 mg.kg(-1) (0.5 ml.kg(-1)) of caudal tramadol before incision, group III (n = 34) received 2 mg.kg(-1) tramadol intravenously, after surgery and group IV (n = 34) received 2 mg.kg(-1) tramadol intravenously, after anaesthesia induction. When the patients were fully awake in the recovery area, heart rate, arterial pressure, peripheral oxygen saturation, respiratory rate, pain and sedation scores were recorded at 5, 10, 15, 30, 60 min, and 2, 3, 4, 6, 12 and 24 h postoperatively and side-effects were noted. Pain was assessed using an objective pain score (OPS). RESULTS: The OPS were lower in caudal tramadol groups than in i.v. tramadol groups only at 3 h (P < 0.05). The duration of postoperative analgesia was longer in the caudal groups than in the i.v. groups (P = 0.001). However, the duration of postoperative analgesia was unaffected by the timing of administration. CONCLUSIONS: Caudal tramadol provides better and longer lasting postoperative analgesia than i.v. tramadol. These results also suggest that preoperative caudal tramadol did not provide any clinically perceptible benefits compared with postoperative caudal tramadol.