A major trauma centre is a specialty hospital not a hospital of specialties.

BACKGROUND: High estimates of preventable death rates have renewed the impetus for national regionalization of trauma care. Institution of a specialist multidisciplinary trauma service and performance improvement programme was hypothesized to have resulted in improved outcomes for severely injured patients. METHODS: This was a comparative analysis of data from the Royal London Hospital (RLH) trauma registry and Trauma Audit and Research Network (England and Wales), 2000-2005. Preventable mortality was evaluated by prospective analysis of the RLH performance improvement programme. RESULTS: Mortality from critical injury at the RLH was 48 per cent lower in 2005 than 2000 (17.9 versus 34.2 per cent; P = 0.001). Overall mortality rates were unchanged for acute hospitals (4.3 versus 4.4 per cent) and other multispecialty hospitals (8.7 versus 7.3 per cent). Secondary transfer mortality in critically injured patients was 53 per cent lower in the regional network than the national average (5.2 versus 11.0 per cent; P = 0.001). Preventable death rates fell from 9 to 2 per cent (P = 0.040) and significant gains were made in critical care and ward bed utilization. CONCLUSION: Institution of a specialist trauma service and performance improvement programme was associated with significant improvements in outcomes that exceeded national variations.

Implementation of a clinical information system in nurse-managed care.

The Penn Nursing Network Information System Project is a collaborative effort of practitioners, academic researchers, and a health-care software developer. The Penn Nursing Network, a group of nurse-managed practices owned and operated by the University of Pennsylvania School of Nursing, has taken a leadership role in the project. PNN is developing an information system specific to the needs of nurse-managed care and creating a data warehouse for nursing centres in the Philadelphia region. Important components of this project include the identification of key data elements to represent the problems treated, interventions performed, and outcomes sensitive to the nursing care provided. The Omaha System provided a useful framework for capturing the necessary data elements. However, additional data were needed. In addition, attention was paid to the development of a software program that would complement the workflow of the practitioner while capturing data efficiently. The main goal of the project is development of a longitudinal database reflective of clinical practice, to be used for both research and evaluation.

A physiologically-based early warning score for ward patients: the association between score and outcome.

We analysed the physiological values and early warning score obtained from 1047 ward patients assessed by an intensive care outreach service. Patients were either referred directly from the wards (n = 245, 23.4%) or were routine critical care follow-ups. Decisions were made to admit 135 patients (12.9%) to a critical care area and limit treatment in another 78 (7.4%). An increasing number of physiological abnormalities was associated with higher hospital mortality (p < 0.0001) ranging from 4.0% with no abnormalities to 51.9% with five or more. An increasing early warning score was associated with more intervention (p < 0.0001) and higher hospital mortality (p < 0.0001). For patients with scores above one (n = 660), decisions to admit to a critical care area or limit treatment were taken in 200 (30.3%). Scores of all physiological variables except temperature contributed to the need for intervention and all variables except temperature and heart rate were associated with hospital mortality.

Use of an implantable left ventricular assist device for irreversible ventricular fibrillation secondary to massive myocardial infarction--a case study.

Mechanical circulatory support devices are currently being developed. The indications for their use are presently following acute myocardial infarction; in post cardiac-surgical cardiogenic shock; and as a mechanical 'bridge' to cardiac transplantation. Devices are being developed for permanent implantation in patients with end-stage left ventricular failure who are unacceptable for or denied transplantation. Intensive care nurses are required to care for patients who receive such mechanical support. These patients need intensive physical care with extensive nursing intervention and psychological support. The following case study describes the care of a patient who received an implantable left ventricular assist device (LVAD). The study illustrates the nursing care required in the management of such patients.

The advantages of haplotype analysis of the promoter region of the human apolipoprotein E gene.

Polymorphisms in the regulatory region of the human apolipoprotein E gene (gene, APOE; protein, apoE) have been implicated in Alzheimer's disease. Here we describe in detail the advantages of a simple method for haplotype analysis of this region (at -491 and -427 bases relative to the transcription start site of the gene). The promoter region of the APOE gene was amplified by polymerase chain reaction (PCR) and this fragment was then used as a template for PCR with "nested" primers to generate a 228-bp product incorporating both the -491 and the -427 loci. PCR products were then digested with DraI and AluI together and subjected to polyacrylamide gel electrophoresis. The distinct pattern of bands appearing on the gel was then used to ascribe [-491,-427] haplotypes to each subject, from which -491 and -427 genotypes were inferred. -491 and -427 genotypes were also confirmed by digestion with DraI alone or AluI alone. Haplotype analysis was successful in all 20 samples analyzed and was 100% consistent with genotyping. We suggest that this is a reliable, time-saving method that the will be useful in large-scale APOE promoter genotyping studies.