Medical service redesign shares the load saving 6000 bed days and improving morale.

BACKGROUND AND AIMS: In 2010, demand on the Auckland City Hospital general medical service exceeded capacity. A review by the Royal Australasian College of Physicians was critical of training offered to registered medical officers, and low morale was a problem across the service. Management offered support for an improved model that would solve these problems. METHODS: A project to redesign the general medical service was undertaken. Baseline analysis found uneven workload and insufficient capacity at peak times for patient presentations. Workshops involving the entire service led to a new model that splits workload and teams into patients likely to have a short stay from those requiring longer, ward-based care. Admissions are now distributed over 12 teams on weekdays and 4 on the weekends. There was an increase of approximately 2.5 in consultant full time equivalents but no change in registrar or house officer staffing. RESULTS: Since the introduction of the new model, the average length of stay has fallen from 3.7 to 3.2 days (14%) and the median length of stay by 28%, resulting in a saving of 6000 bed days per year. Readmission, inpatient and 30-day mortality rates are unchanged. These results have been sustained over 18 months with signs of continuing improvement. CONCLUSION: This project owes its success to the following factors - management support; iterative engagement of a range of staff; provision of timely data analysis; increases in senior medical officer staffing and reorganisation leading to more predictable and fair work practices. One challenge is discontinuity, whether between doctors and patients or within the medical team.

Effect of incorrect gestational dating on Down's syndrome and neural tube risk assessment.

Down's syndrome risks are estimated between 15 and 20 completed weeks' gestation (cGW) using an algorithm involving maternal age and serum alpha-fetoprotein (AFP), chorionic gonadotrophin and unconjugated oestriol levels, each expressed as a multiple of the median level (MoM) at the cGW. The AFP MoM itself is the basis for screening for open neural tube defects (oNTD). Because medians change during this period, gestational dating must be accurate so that appropriate medians are used. A calculated Down's syndrome risk > 1:380 at term is generally considered to indicate a 'high-risk' pregnancy. This study focused on 378 patients with reported risk < or = 1:500 based on physician-supplied cGW (and hence considered at 'low risk' for Down's syndrome) to determine the effect of common 1-2-week dating errors on risk estimates. Using the original analytical data, each patient's risk was recalculated for each week over the 15-20 weeks, and classified into three categories: < 1:380 'low'; 1:380-1:100 'moderate'; and > 1:100 'high'. Advancing originally 'low-risk' patients by one week increased the risk by 1.09-14.1 times (median 3.18, mean 3.60); 46 (12.2%) became 'moderate' and 2 (0.5%) became 'high' risk. Advancing by two weeks increased risks 1.58-60.5 times (median 10.03, mean 12.04); 131 (36.5%) became 'moderate' and 39 (10.9%) became 'high' risk. Predictably, oNTD screening results also were affected. Although 1-2 week differences in AFP medians had little effect on most patients in this study sample, some who originally were oNTD negative became oNTD positive, whereas others who had been oNTD positive became screen negative. Thus, in many cases, a 1-2 week dating error may have only minimal effect on the estimated risks for chromosome or neural tube defects, but in other cases the effect of such an error would be significant.

Safety and efficacy of intravesical aminocaproic acid for bleeding after transurethral resection of prostate.

There appears to be no clinically significant difference in blood loss or transfusion requirements after transurethral resection of the prostate (TURP) when intravesical 0.5% aminocaproic acid is compared with 0.9% sodium chloride irrigation in patients during the first three days after surgery. This is probably because early post-TURP bleeding is due to inadequate hemostasis or perforation of the prostatic capsule, and not excessive local or systemic fibrinolysis. However, we suggest that intravesical aminocaproic acid might be a useful alternative to systemic antifibrinolytic therapy in patients with delayed, recurrent, excessive post-prostatectomy bleeding, which is thought to be due to fibrinolysis. Since aminocaproic acid is not systemically absorbed after bladder instillation, intravesical administration causes few side effects and does not necessitate screening patients for disseminated intravascular coagulation prior to treatment.

Cancer chemotherapy - a new approach.

A considerable body of evidence indicates that interference with amino acid metabolism could be used as a basis for a concerted attack on tumor growth. Tumor cells are known to concentrate amino acids; the same transport mechanisms cause them to concentrate amino acid analogues as well. Furthermore, the growth of many tumors if affected by deficiences of certain amino acids. This apparent vulnerability of tumors points to a new approach to in vivo testing and clinical trials of amino acid analogues for efficacy against tumor growth. This approach consists of creating a dietary deficiency of an amino acid, replacing the amino acid by a toxic analogue which would be selectively concentrated by the tumor, followed at the appropriate time by restoration of the normal dietary level of the natural amino acid to allow growth of normal tissues.

Correlation between morning urine estriol concentration and 24-hour estriol excretion.

In an attempt to circumvent the need for 24-hour urine collections for estriol analyses in assessment of fetal status, the possibility of using morning urine samples was investigated. Results indicate 1) good correlation between 24-hour estriol excretion and morning estriol concentration, and between corresponding E/C ratios, 2) similar morning and 24-hour estriol concentrations, 3) high dependence of estriol and creatinine excretion on 24-hour urine volume but not on morning volume, 4) larger variations in 24-hour than in morning urine volume, and 5) better consistency of values in morning than in 24-hour samples in pathologic pregnancy. The use of serial morning urine concentrations at least as an outpatient monitoring procedure is suggested.

Rapid determination of urine estriol by an on-column derivatization procedure.

Estriol in pregnancy urine is determined by acid hydrolysis of steroid conjugates, followed by ether and aqueous sodium hydroxide extraction and gas chromatography. Derivatives are formed within the injection port of the gas chromatograph using tetramethylammonium hydroxide. Several samples may be processed simultaneously. Hydrolysis and extraction of a specimen are done in a single culture tube; for larger numbers of specimens, a Paton-Brown extractor may be used. With a two-column gas chromatograph, results on two specimens are available within one hour; twelve analyses may be completed within two hours.

Apparatus for preparation of bacterial extracellular enzymes.

A method is described for the growth of bacteria within dialysis tubing to yield extracellular enzymes, or, possibly, other nondialyzable extracellular products, in concentrated form.