Ward round checklist improves patient perception of care.

BACKGROUND: Checklists have been shown to reduce morbidity and mortality in medicine by improving documentation and reducing errors. In the modern era of care, where patients are the centre of decision-making, this study examines patient perception of care and error prevention with the use of ward round checklist. METHODS: We conducted a prospective stepped-wedge cluster randomized controlled checklist intervention study using a standardized questionnaire to investigate patients' perception of ward rounds before and after implementation of a ward round checklist. RESULTS: A total of 124 patients completed the questionnaire. The overall percentage of items endorsed increased significantly by 5.1% from 64.8% to 70.0% (P = 0.014). Statistically significant improvements were seen in patients knowing their diagnosis (P = 0.027), the day's plan (P = 0.038), observing a medication chart (P < 0.001) and observation chart review (P = 0.008). CONCLUSION: Our study indicates that the use of a ward round checklist leads to patient-perceived improvements in aspects of quality of care.

Perioperative shared decision-making in the Bay of Plenty, New Zealand: Audit results from a complex decision pathway quality improvement initiative using a structured communication tool.

Patients presenting for elective surgery in the Bay of Plenty area in New Zealand are increasingly elderly with significant medical comorbidities. For these patients the risk-benefit balance of undergoing surgery can be complex. We recognised the need for a robust shared decision-making pathway within our perioperative medicine service. We describe the setup of a complex decision pathway within our district health board and report on the audit data from our first 49 patients. The complex decision pathway encourages surgeons to identify high-risk patients who will benefit from shared decision-making, manages input from multiple specialists as needed with excellent communication between those specialists, and provides a patient-centred approach to decision-making using a structured communication tool.

A unique approach to thoracic duct leak after esophagectomy.

Chylothorax is a severe complication of esophagectomy. Those who do not respond to conservative measures require reoperation. We have described a minimally invasive technique to control a late postoperative chyle leak. A 41-year-old patient underwent an Ivor-Lewis esophagectomy. Day 4 after surgery he was found to have an esophageal leak. He underwent thoracotomy and esophageal stent insertion. On day 20, a radiologic drain was placed to control a small supradiaphragmatic collection. The collection was found to be chyle, and 2.5 L was drained per day. As this was 3 weeks after thoracotomy, a technique of sinus track dilatation and cavity visualization was carried out with clipping of the chyle channel. The patient recovered well from the procedure. He was extubated postoperatively and only required simple analgesia.

National survey of fluid therapy in acute pancreatitis: current practice lacks a sound evidence base.

BACKGROUND: Fluid therapy (FT) is a critical intervention in managing acute pancreatitis (AP). There is a paucity of evidence to guide FT and virtually no data on current prescribing practice. This survey aims to characterize current practice and opinion with regard to FT in AP throughout New Zealand. METHODS: Information was collected on fluid selection, administration, and goal-directed FT. The survey was distributed online and in print to all doctors employed in General Surgery Departments in New Zealand on 1 May 2012. Monthly email reminders were sent for 6 months. RESULTS: The overall response rate was 47 % (n = 190/408). Crystalloids were the preferred initial fluid for all categories of severity; however, colloid use increased with severity (p < 0.001). Fluid volume also increased with severity (p = 0.001), with 74 % of respondents prescribing >4 L for AP with organ failure (OF). Clinicians treating 26-50 patients per year with AP were less likely to prescribe colloid for AP with OF (8 vs 43 %) (p = 0.001). Rate of fluid administration in AP with OF varied according to physicians' seniority (p = 0.004); consultants prescribed >4 L more than other groups (83 vs 68 %). Only 17 % of respondents reported the use of guidelines. CONCLUSIONS: This survey reveals significant variation in prescription of FT for AP, and aggressive FT is commonly prescribed for AP with OF. There is little adherence to published guidelines or best available evidence.

A comprehensive classification of invasive procedures for treating the local complications of acute pancreatitis based on visualization, route, and purpose.

BACKGROUND/AIMS: The lack of a system to classify invasive procedures to treat local complications of acute pancreatitis is an obstacle to comparing interventions. This study aimed to develop and validate a comprehensive multidisciplinary classification. METHODS: Standardized terminology was used to develop a classification of procedures based on three key components: how the lesion is visualized, the route used during the procedure, and the procedure's purpose. Gastroenterologists, radiologists, and surgeons (n = 22) from three New Zealand centers independently classified 15 published technique descriptions. Inter-rater reliability was calculated for each component. The classification's clarity, ease of use, and potential to achieve its objectives were rated on a Likert scale. RESULTS: The classification's clarity, ease of use, and potential to achieve its objectives had median scores of 4/5. Inter-rater reliability for visualization, route, and purpose components was substantial at 0.73 (95% CI 0.63-0.82), 0.79 (95% CI 0.70-0.87), and 0.64 (95% CI 0.53-0.74), respectively. CONCLUSIONS: This article describes the development and validation of a comprehensive classification for the wide range of procedures used to treat the local complications of acute pancreatitis. It has substantial inter-rater reliability and high acceptability, which should enhance communication between clinicians and facilitate comparison between procedures.

Survey of trends in minimally invasive intervention for necrotizing pancreatitis.

BACKGROUND: Minimally invasive techniques to manage infected pancreatic necrosis have been recently developed and changes in their pattern of use are unknown. The aims of this survey were to determine the trends in the role of minimally invasive techniques to manage infected complications of necrotizing pancreatitis and the barriers to performing minimally invasive necrosectomy in Australia and New Zealand. METHODS: Members of the Australian and New Zealand Hepatic Pancreatic and Biliary Association were surveyed. Participant demographics and necrotizing pancreatitis caseload were determined. The perceived role of percutaneous catheter drainage and minimally invasive necrosectomy for pancreatic abscess, infected pseudocyst and infected pancreatic necrosis were scored on Likert scales, comparing 2002 with 2007. Barriers to performing minimally invasive necrosectomy were scored. RESULTS: The response rate was 49% (44/90). Between 2002 and 2007, the role of percutaneous catheter drainage became more important as primary (P= 0.05) and secondary (P= 0.01) treatment for pancreatic abscess, and prior to minimally invasive necrosectomy for abscess, pseudocyst and necrosis (P < 0.01). Minimally invasive necrosectomy became increasingly important as primary treatment for infected necrosis (P < 0.01) and had been used by 47% of respondents. The greatest barriers to performing minimally invasive necrosectomy were lack of training and experience in the techniques, and the anatomical position and complexity of the target lesion. CONCLUSION: Minimally invasive techniques have an increasingly important perceived role in the management of pancreatic abscess, infected pseudocyst and infected pancreatic necrosis. Further evidence is required to determine the best techniques for treating each form of infection associated with necrotizing pancreatitis.

Telling the truth to Asian patients in the hospital setting.

Full disclosure of health information to patients is considered important in Western culture, but may be less appropriate for patients from other cultures, particularly when conveying news about a diagnosis with a poor prognosis. This issue is becoming important in New Zealand, given the rapidly increasing ethnic diversity of patients presenting to our hospitals. This paper explores culturally appropriate ways of breaking bad news to patients of different ethnicities in the hospital setting, with emphasis on identifying the locus of decision-making within families and decision-making about end-of-life care. Given that the most rapid population growth is presently occurring in the Asian community, attention is focussed on culturally sensitive ways of breaking bad news to Asian patients and their families.

Functional matrix metalloproteinase-9 polymorphism (C-1562T) associated with abdominal aortic aneurysm.

PURPOSE: Matrix metalloproteinase-9 (MMP-9) is a potent endopeptidase with activity against both collagens and elastin. Expression of MMP-9 is elevated in vascular disease, and in particular within aneurysm tissues. This study tested the hypothesis that the functionally more active T allele of the MMP9 C-1562T polymorphism may be overrepresented in patients with abdominal aortic aneurysm (AAA) compared with control subjects and patients with atherosclerotic peripheral vascular disease (PVD). METHODS: Seven hundred eighty-nine unrelated persons (AAA, n = 414; control subjects, n = 203; PVD, n = 172) were genotyped for the common C-1562T functional promoter polymorphism of the MMP9 gene. RESULTS: Genotypes containing the T allele of this polymorphism were significantly more common in patients with AAA compared with both control subjects and patients with PVD (adjusted odds ratio, 2.41 and 2.94, respectively). The greatest shift between groups was observed in male patients, with a difference of 20.6% in CT/TT genotypes. and 12.1% in T allele frequency between patients with AAA compared with patients with PVD. CONCLUSIONS: This study provides further evidence to support the role of MMP-9 in the pathogenesis of AAA, and indicates that the MMP9 C-1562T functional polymorphism may represent a genetic component contributing to susceptibility to this vascular disease.