Intensive care unit staffing during the periods of fluctuating bed occupancy: An alternative dynamic model.

OBJECTIVES: Staffing is the single biggest cost component in the critical care budgets. Due to the fluctuation in both bed occupancy and the level of care needs, nursing staff requirement can vary considerably from day to day. This makes the traditional 'fixed roster' staffing system inefficient, costly and potentially unsafe. In this study, we used the existing bed occupancy data to test the viability two 'dynamic' workforce management models. RESEARCH METHODOLOGY: Nursing requirement data were prospectively collected over one year at a thirty-two-bed critical care unit. Using mathematical models, we then tested the concept of two alternative workforce management models and compared the level of staffing, as well as the estimated cost per year. The first was an 'on-call' model, which was a two-tier roster with a standard staffing level and an additional on-call component; the second was a 'predictive' model, which estimated the staffing requirement based on the bed occupancy a few days prior. SETTING: Single centre study in a busy district general hospital with a 32-bed critical care unit. MAIN OUTCOME MEASURES: The number of days with safe staffing levels and the cost of the alternative workforce management models. RESULTS: Data were collected over 331 days. The on-call model was estimated to cost 16% less per year (£431,320, or 2,630 nurse-shift equivalent) compared to the fixed roster, while fulfilling the adequate staffing standards in 97% of the days. While the predictive model could also be used to improve the workforce efficiency, this was overall less efficient than the on-call model. CONCLUSION: The modelled data suggests that the implementation of an 'on-call' model in critical care nursing rostering could potentially improve coverage and appear to be cost effective.

Nutrient intake of women with and without gestational diabetes with a specific focus on fatty acids.

OBJECTIVE: Diet therapy is the cornerstone for the management of gestational diabetes mellitus (GDM). Women with GDM are commonly given dietary advice that broadly focuses on a reduction of total energy and fat consumption. We compared nutrient intake and specifically fatty acids of women with GDM who had received individualized nutritional counseling with those of non-diabetic women who did not. METHOD: Women with GDM (n=44) and healthy pregnant women (n=44) with uncomplicated singleton pregnancies were recruited during the third trimester. Women with GDM were given consultation on diet, health, and macronutrient content of foods commonly consumed by the individual. The non-diabetic group did not receive any dietary advice. Both groups were asked to keep a detailed record of all of foods and fluid consumed over a 4-d period. RESULTS: After dietary counseling, the GDM group had lower intakes of energy (P<0.05), refined sugar (P<0.0001), total and saturated fats (P<0.0001), and monounsaturated (P<0.01) and trans (P<0.0001) fatty acids and higher levels of docosahexaenoic acid and fiber (P<0.05) compared with the non-diabetic group. CONCLUSIONS: Individualized dietary advice was associated with a lower consumption of the target nutrients in women with GDM. Another benefit of the advice was a slight increase in intake of eicosapentaenoic and docosahexaenoic acids, although consumption of omega-3 fatty acids by both groups was well below the recommendations for pregnancy. There is evidence that docosahexaenoic acid modulates insulin resistance and that it is vital for neurovisual development. We suggest that dietary management for women with GDM should foster the current recommendations for essential fatty acids in pregnancy.

Unfavorable effect of type 1 and type 2 diabetes on maternal and fetal essential fatty acid status: a potential marker of fetal insulin resistance.

BACKGROUND: Pregestational maternal diabetes increases obesity and diabetes risks in the offspring. Both conditions are characterized by insulin resistance, and diabetes is associated with low membrane arachidonic (AA) and docosahexaenoic (DHA) acids. OBJECTIVE: We investigated whether type 1 and type 2 diabetes in pregnancy compromise maternal and fetal membrane essential fatty acids (FAs). DESIGN: We studied 39 nondiabetic (control subjects), 32 type 1 diabetic, and 17 type 2 diabetic pregnant women and the infants they delivered. Maternal and cord blood samples were obtained at midgestation and at delivery, respectively. Plasma triacylglycerols and choline phosphoglycerides and red blood cell (RBC) choline and ethanolamine phosphoglyceride FAs were assessed. RESULTS: The difference in maternal plasma triacylglycerol FAs between groups was not significant. However, the type 1 diabetes group had lower plasma choline phosphoglyceride DHA (3.7 +/- 0.9%; P < 0.01) than did the control group (5.2 +/- 1.6%). Likewise, RBC DHA was lower in the type 1 [choline: 3.4 +/- 1.5% (P < 0.01); ethanolamine: 5.9 +/- 2.5% (P < 0.05)] and type 2 [choline: 3.5 +/- 1.6% (P < 0.05)] diabetes groups than in the control group (choline: 5.5 +/- 2.2%; ethanolamine: 7.5 +/- 2.5%). Cord AA and DHA were lower in the plasma (type 1: P < 0.01) and RBC (type 2: P < 0.05) choline phosphoglycerides of the diabetics than of the control subjects, and cord RBC ethanolamine phosphoglycerides were lower in DHA (P < 0.05) in both diabetes groups than in the control group. CONCLUSIONS: Diabetes (either type) compromises maternal RBC DHA and cord plasma and RBC AA and DHA. The association of these 2 FAs with insulin sensitivity may mean that the current finding explains the higher incidence of insulin resistance and diabetes in the offspring of diabetic women.

The impact of an out-reach clinic on referral of patients with renal impairment.

BACKGROUND: Early diagnosis and prompt treatment of a number of renal diseases may delay renal failure, obviate the need for renal replacement therapy and reduce co-morbidity. The aim of this study was to examine the impact of out-reach renal clinics on patterns of referral of patients with renal impairment to a nephrologist. METHODS: The number of patients with renal impairment was determined as defined by serum creatinine levels >150 micromol/l in three centres within a single NHS trust over two separate 1-week periods. None of the centres studied has a local nephrologist, however one centre (hospital A) has renal out-reach clinics, another is geographically close to a renal unit (hospital B), while the third unit (hospital C) has no nephrology presence and is geographically furthest from the renal unit. In addition, retrospective as well as follow-up data on the renal function of all patients with renal impairment was collected. RESULTS: In hospital A, there was a lower proportion of patients with unreferred renal impairment than in the other two hospitals. Within the unreferred patient group there were significantly more patients whose renal function improved during the follow-up period. A considerable proportion of patients with documented deterioration in renal function remained unknown to nephrology services 6 months after initial presentation. Other than the presence of an onsite nephrology service, the only other factor found to be significantly different in those patients not referred to nephrologists was age: as in all three centres, those not referred were significantly older. CONCLUSION: Inequity of access to renal services is an important obstacle to early referral of patients with impaired renal function. Out-reach renal services provide a model which significantly improves referral patterns.

Type 1 diabetes compromises plasma arachidonic and docosahexaenoic acids in newborn babies.

The activity of delta6- and delta5-desaturase, enzymes required for the synthesis of AA and DHA, are impaired in human and experimental diabetes. We have investigated whether neonates of type 1 diabetic women have compromised plasma AA and DHA at birth. Cord blood was obtained from healthy babies born to mothers with (n = 31) and without (n = 59) type 1 diabetes. FA composition of plasma choline phosphoglycerides (CPG), TG, and cholesterol esters (CE) was assayed. The neonates of the diabetics had lower levels of AA (20:4n-6, P< 0.0001), adrenic acid (22:4n-6, P < 0.01), sigman-6 metabolites (P < 0.0001), docosapentaenoic acid (22:5n-3, P < 0.0001), DHA (22:6n-3, P < 0.0001), sigman-3 (P < 0.0001), and sigman-3 metabolites (P< 0.0001) in CPG compared with the corresponding babies of the nondiabetic mothers. Similarly, they had lower levels of AA (P< 0.05), sigman-6 metabolites (P < 0.05), DHA (P< 0.0001), and sigman-3 metabolites (P< 0.01) in plasma CE. There was also a nonsignificant reduction of AA and DHA in TG in the babies of the diabetic group. The current investigation indicates that healthy neonates born to mothers with type 1 diabetes have highly compromised levels of AA and DHA. These nutrients are of critical importance for neurovisual and vascular system development. In poorly controlled maternal diabetes, it is conceivable that the relative "insufficiency" of AA and DHA may exacerbate speech and reading impairments, behavioral disorders, suboptimal performance on developmental tests, and lower IQ, which have been reported in some children born to mothers with type 1 diabetes mellitus. Further studies are needed to understand the underlying mechanism for this biochemical abnormality and its implications for fetal and infant development.

The transdermal revolution.

Historically, developments in transdermal drug delivery have been incremental, focusing on overcoming problems associated with the barrier properties of the skin, reducing skin irritation rates and improving the aesthetics associated with passive patch systems. More-recent advances have concentrated on the development of non-passive systems to aid delivery of larger drug molecules, such as proteins and nucleotides, as the trend for discovering and designing biopharmaceuticals continues. Fundamentally, improvements in transdermal delivery will remain incremental until there is wider acceptance of this route of administration within the pharmaceutical industry. Only then will the transdermal revolution live up to its true potential.