Improving accuracy and efficiency of early warning scores in acute care.

BACKGROUND: Early warning scores (EWS) are an integral part of the care of acutely ill patients. Unfortunately, in the few studies where the accuracy of EWS has been tested it has been found to be lacking, with serious implications for quality of care. AIM: To determine if the provision of computer-aided scoring could increase the accuracy and efficiency of EWS calculations, when compared with the traditional pen-and-paper method, and to determine if it was acceptable to users. DESIGN: 26 nurses from two surgical assessment wards in two hospitals were studied. The study was conducted in three phases. Phase 1--a classroom-based exercise where nurses were given ten patient vignettes and asked to derive EWS using traditional pen-and-paper methods; Phase 2--the same as phase 1, but using a hand-held computer to derive EWS; Phase 3--the same as phase 2, but was a follow-up exercise undertaken in the ward environment, 4 weeks after computer-aided scoring was implemented in the two wards. Each phase closed with a user perception/attitudes questionnaire. RESULTS: Accuracy and efficiency--phase 1 was associated with a significantly lower overall accuracy (152/260, 58%) compared with phase 2 (96%; difference in proportions 38%, 95% confidence interval 31-44%, P < 0.0001). There was a small but significant reduction in accuracy from phase 2 (96%) to phase 3 (88%) (8% difference, P=0.006). The mean time to derive an EWS reduced from 37.9 seconds in phase 1 to 35.1 seconds in phase 2 (P=0.016), down to 24.0 seconds in phase 3 (P<0.0001). User acceptability: in phase 1, nurses favoured the pen-and-paper method in all respects except accuracy. In phase 2, nurses' views shifted significantly in favour of the hand-held computer, with little deterioration in the follow-up phase 3. CONCLUSIONS: A hand-held computer helps to improve the accuracy and efficiency of EWS in acute hospital care and is acceptable to nurses.

Assessment of the implementation of a national patient safety alert to reduce wrong site surgery.

BACKGROUND: In 2005, guidance on how to prevent wrong site surgery in the form of a national safety alert was issued to all NHS hospital trusts in England and Wales by the National Patient Safety Agency. OBJECTIVE: To investigate the response to the alert among clinicians in England and Wales 12-15 months after it had been issued. METHODS: A before-after study, using telephone/face-to-face interviews with consultant surgeons and senior nurses in ophthalmology, orthopaedics and urology in 11 NHS hospitals in England & Wales in the year prior to the alert and 12-15 months after. The interviews were coded and analysed thematically. RESULTS: The study revealed marked heterogeneity in organisational processes in response to a national alert. There was a significant change in surgeons' self-reported practice, with only 48% of surgeons routinely marking patients prior to the alert and 85% after (p<0.001). However, inter-specialty differences remained and change in practice was not always matched by change in attitude. Compliance with the detailed recommendations about how marking should be carried out was inconsistent. There were unintended consequences in terms of greater bureaucracy and concerns about diffusion of responsibility and hastily performed marking to enable release of patients from wards. CONCLUSION: The alert was effective in promoting presurgical marking and encouraging awareness of safety issues in relation to correct site surgery. However, care should be taken to monitor unintended consequences and whether change is sustained. Greater flexibility for local adaptation coupled with better design and early testing of safety alerts prior to national dissemination may facilitate more sustainable changes in practice.

A re-audit of pulmonary function laboratories in the West Midlands.

In 1991 the West Midlands Pulmonary Function Audit Group examined the consistency between pulmonary function laboratories in the West Midlands. Three healthy subjects visited 22 centres and performed a standard set of pulmonary function tests. Demographic data on nine hypothetical subjects was also supplied for the laboratories to produce predicted values. Equipment was checked for accuracy using standard methods. The 1991 audit revealed significant inter-laboratory variability. Sources of error were identified and after consultation, recommendations were made to improve consistency. In addition, national and regional training workshops were organized for laboratory staff. In 1995 the audit was repeated using the same three subjects. Significant differences continued for all predicted results except for residual volume (RV) and forced vital capacity (FVC) and for all measured results except for functional residual capacity (FRC). However, improvements in the coefficient of variation were seen compared with 1991 for predicted forced expiratory volume (FEV1), total lung capacity (TLC), gas transfer (TLCO), FVC, FRC and RV. Similar improvements were seen in measured results for FEV1 and FVC. Increased variation was seen for predicted corrected transfer factor (KCO) and actual RV. The majority of variables in the 1995 audit had a coefficient of variation of less than 5% between laboratories. Analysis of the predicted results from the hypothetical subjects continued to show unacceptable variation reflecting continuing computer algorithm inconsistency. The improvements seen are encouraging and suggest that a regular audit programme is worthwhile.

An audit of pulmonary function laboratories in the West Midlands.

BACKGROUND: Pulmonary function testing has become an integral part of the assessment and follow-up of patients with pulmonary disease. Many factors can influence the results produced by a laboratory. This audit was performed to examine the extent of variation in the pulmonary function test results amongst all laboratories in the West Midlands. This was followed by an attempt to determine the cause of this variation. METHODS: Phase 1. Three normal healthy subjects each underwent a set of pulmonary function tests in all 22 laboratories in the West Midlands. Information regarding technicians' qualifications, training and seniority, protocol and equipment used were obtained in the form of a questionnaire. Phase 2. All 22 laboratories were asked to calculate the predicted values on the same nine sets of demographic data. These data included both sexes, ethnic minorities and range of ages. In addition technical aspects of each laboratory were investigated including the assessment of volume and gas analysers with standard gases containing known concentrations of helium and carbon monoxide. RESULTS: Phase 1. Significant variations (P < 0.05) were observed in all measured values of pulmonary function tests of the three subjects. Significant variations (P < 0.05) were also observed in all predicted values except total lung capacity. Phase 2. There were significant variations (P < 0.05) amongst laboratories in calculating the predicted values of all components of pulmonary function tests. No significant differences were observed in the measurement of volume or concentration of carbon monoxide or helium.

Consistency of morning stiffness: an analysis of diary data.

This study aimed to determine the within-individual daily variation in morning stiffness (MS) of RA patients, and to validate the routine clinically derived duration of MS against that recorded prospectively by patients. Forty-nine RA patients, who during a detailed clinical interview reported experiencing MS that week were studied. They were asked to prospectively record, using a diary, daily information on the duration of their MS. The times both of waking and of getting up were noted, as well as the times to first improvement, maximum improvement and complete disappearance of MS, providing six possible estimates of MS duration, three of which, using waking as starting points, could be compared with the interview. The daily variation of MS was assessed by the within-patient range. The median duration of the diary scores was then compared with the MS estimates recorded at the interview. There was a large intra-individual variation in duration of MS, whichever of the six definitions were used. Half of the patients recorded ranges of MS scores of 3 h or more within the same week. There was also marked variation between the median diary derived duration and that ascertained by interview. This variation was at its smallest when the duration of MS was calculated as time until maximum improvement. The routine recording of the 'typical' duration of MS seems to have little clinical value in the face of the large within-patient variation. Of the possible choices for estimating duration, the time from waking to maximum improvement appeared to be the best indicator of the average duration of MS in RA patients.

A reevaluation of the symptom of morning stiffness.

OBJECTIVE: To study, both qualitatively and quantitatively, morning stiffness in consecutive patients attending a rheumatology clinic. METHODS: A detailed interview from 93 patients with rheumatoid arthritis (RA) and 46 patients with noninflammatory joint disease. RESULTS: Occurrence, duration and severity of morning stiffness were similar in both groups, as was its detailed qualitative description. Patients with RA with active disease had higher severity scores of morning stiffness than those with inactive disease. CONCLUSION: Morning stiffness is a poor discriminator between RA and noninflammatory joint disease. Its assessment by a severity score is better than one based on duration.

Desirable behaviours in the office management of hypertension addressed through continuing medical education.

Twenty family physicians in Saskatchewan participated in this randomized controlled study which examined the effects of relatively low-cost educational techniques on the office management of hypertension. We measured 1,538 episodes of care relating to the office management of hypertension by chart review, prior to, and at six and 12 months following education. The family physicians who participated in the education were found to perform the recommended behaviours significantly more often at six and 12 months post education than those physicians who did not have the education. Our findings indicate that carefully planned, inexpensive educational techniques can improve clinical behaviour in areas where there is identified educational need.

The effects of continuing medical education on family doctor performance in office practice: a randomized control study.

A randomized controlled study was conducted to determine if specifically designed continuing medical education in the fields of cardiovascular and cancer medicine could change doctor office behaviour significantly. Thirty-one volunteer family doctors from 25 offices participated. Six (three cardiovascular and three cancer) learning objectives were defined. Two educational formats were selected as the independent variables: (1) group interaction opportunities (face-to-face and teleconference); and (2) concisely written newsletters. Chart measures of doctor performance prior to and 6 and 12 months following education served as the dependent variables. The family doctors receiving education were found to perform the recommended behaviours significantly more than those who did not receive the education (P less than 0.05) at 6 months post-education. This difference was maintained at the 12-month post-educational period for one of the educational programmes offered. A carefully planned programme of continuing medical education will result in favourable changes in the office practice of volunteer doctors. These changes can persist for as long as 12 months. Adherence to several essential learning principles is required.

Anomalous left coronary artery from the pulmonary artery: effect of coronary anatomy on clinical course.

Nine children and 1 adolescent with anomalous left coronary artery from the pulmonary trunk (ALCA) were studied between 1970 and 1982. Serial angiographic and hemodynamic data are compared with the clinical course. Four patients had separate conus coronary arteries with a major contribution to collateral flow. Eight patients survived various surgical procedures with 1 late death, 1 awaits operation, and 1 died in infancy. The authors' data show a significant potential for improvement in left ventricular function as shown by an increase in LV ejection fraction on medical therapy alone (5/6 patients), including all 4 with separate conus coronary arteries. The authors conclude that medical treatment alone may be indicated for a time in selected patients with ALCA, and a subgroup with a separate conus coronary artery may have a more favorable natural history.

Designing education interventions to improve physician performance in office practice.

Family doctors play a very important role in determining the health of the populace; however, surveys and expert opinions indicate that there is considerable room for improvement in the knowledge and skills of family physicians concerning the prevention, early detection and management of the major causes of death and disability. Effective Continuing Medical Education (CME) could help greatly to resolve this problem. THere is, however, little evidence that presently available systems of CME, though costly, are effective in improving either physician competence or patient health. Attractive and cost-effective CME methods are greatly needed. This study develops, field tests and evaluates more efficient office-based CME programs for family doctors. Prevention, early detection and improved management of cardiovascular disease and cancer are the primary goals. A pretest posttest control group and time series approach was chosen for the experimental design. Thirty-one family physicians are participating. Physician performance and patient outcome prior to and after education are being assessed largely through office record review.

Symptom relief and the placebo effect in the trial of an anti-peptic drug.

In order to determine some of the factors involved in the response of duodenal ulcers to placebo treatment, the following factors were studied prospectively during a double-blind, placebo-controlled trial: demographic data; duration of illness and effect of treatment; expectation of success or failure of the new drug; presence of psychiatric problems; and suggestibility. Healing (measured by endoscopy) occurred in 37 patients, 17 of whom were receiving placebo; relief of symptoms occurred in 35 patients, 16 of whom were receiving placebo. There was no significant difference between drug and placebo. Healing was significantly associated with relief of symptoms but with no other variable. Relief of symptoms was more common in male patients and in those from higher social classes, as well as in patients who expected a complete cure and those without evidence of psychiatric problems. the natural history of the disease may be different in these patients. Unexpectedly, suggestibility was not associated with healing or relief of symptoms in the patients receiving placebo.

Sjögren's syndrome terminating as a myeloproliferative disorder.

A 59 year old female was diagnosed as having Sjögren's syndrome in 1963. A short time later, she developed a refractory sideroblastic anemia. In 1972, she was found to have a preleukemic state with a persistent "shift to the left" of the granulocytic series, terminating early in 1974 as acute myeloblastic leukemia. Although several cases of malignant lymphomata have been described in association with Sjörgen's syndrome, to our knowledge no other example of Sjörgen's syndrome has been described in association with a myeloproliferative disorder. Defective immune surveillance produced by the Sjörgen's syndrome may have permitted the development of the myeloproliferative syndrome. Alternatively, both disorders may have developed from a hemopoietic stem cell defect.

Use and abuse of propranolol.

Propranolol has been available to clinical medicine for over a decade. It was used initially in the treatment of tachyarrhythmias and angina pectoris but now has much more widespread application. Recently the drug is being used more frequently in the treatment of hypertension, and its indications are discussed.The metabolism and clearance in the liver has major effects on the serum level. With improved knowledge of the properties and adverse effects of this potent agent, it is now possible to apply better patient selection.

Three years' experience with implanted pacemakers.

At the University Hospital, Saskatoon, over the last three years, pacemakers have been inserted in 40 patients with complete or incomplete heart block. Fourteen of the patients were females and 26 were males. The average age was 65 years; 12 were over 80 years of age, and the youngest patient was 8 years of age. In none was the heart block due to operation. Thirty-three patients are still alive and well. There have been seven deaths three early and four late. One patient died because of a "runaway" pacemaker, and two as a result of infection persisting around the pacemaker. Twenty-nine Medtronic pacemakers were used and 14 Atricor pacemakers; currently we favour the latter instrument.