Application of analytic hierarchy process for measuring and comparing the global performance of intensive care units.

PURPOSE: To develop a model for the global performance measurement of intensive care units (ICUs) and to apply that model to compare the services for quality improvement. MATERIALS AND METHODS: Analytic hierarchy process, a multiple-attribute decision-making technique, is used in this study to evolve such a model. The steps consisted of identifying the critical success factors for the best performance of an ICU, identifying subfactors that influence the critical factors, comparing them pairwise, deriving their relative importance and ratings, and calculating the cumulative performance according to the attributes of a given ICU. Every step in the model was derived by group discussions, brainstorming, and consensus among intensivists. RESULTS: The model was applied to 3 ICUs, 1 each in Barbados, Trinidad, and India in tertiary care teaching hospitals of similar setting. The cumulative performance rating of the Barbados ICU was 1.17 when compared with that of Trinidad and Indian ICU, which were 0.82 and 0.75, respectively, showing that the Trinidad and Indian ICUs performed 70% and 64% with respect to Barbados ICU. The model also enabled identifying specific areas where the ICUs did not perform well, which helped to improvise those areas. CONCLUSIONS: Analytic hierarchy process is a very useful model to measure the global performance of an ICU.

Application of analytic hierarchy process for measuring and comparing the global performance of intensive care units

Purpose: To develop a model for the global performance measurement of intensive care units (ICUs) and to apply that model to compare the services for quality improvement. Materials and Methods: Analytic hierarchy process, a multiple-attribute decision-making technique, is used in this study to evolve such a model. The steps consisted of identifying the critical success factors for the best performance of an ICU, identifying subfactors that influence the critical factors, comparing them pairwise, deriving their relative importance and ratings, and calculating the cumulative performance according to the attributes of a given ICU. Every step in the model was derived by group discussions, brainstorming, and consensus among intensivists. Results: The model was applied to 3 ICUs, 1 each in Barbados, Trinidad, and India in tertiary care teaching hospitals of similar setting. The cumulative performance rating of the Barbados ICU was 1.17 when compared with that of Trinidad and Indian ICU, which were 0.82 and 0.75, respectively, showing that the Trinidad and Indian ICUs performed 70 per cent and 64 per cent with respect to Barbados ICU. The model also enabled identifying specific areas where the ICUs did not perform well, which helped to improvise those areas. Conclusions: Analytic hierarchy process is a very useful model to measure the global performance of an ICU.

A new tool for measurement of process-based performance of multispecialty tertiary care hospitals.

There is an increasing need of a model for the process-based performance measurement of multispecialty tertiary care hospitals for quality improvement. Analytic hierarchy process (AHP) is utilized in this study to evolve such a model. Each step in the model was derived by group-discussions and brainstorming sessions among experienced clinicians and managers. This tool was applied to two tertiary care teaching hospitals in Barbados and India. The model enabled identification of specific areas where neither hospital performed very well, and helped to suggest recommendations to improve those areas. AHP is recommended as a valuable tool to measure the process-based performance of multispecialty tertiary care hospitals.

A new tool for measurement of process-based performance of multispecialty tertiary care hospitals

There is an increasing need of a model for the process-based performance measurement of multispecialty tertiary care hospitals for quality improvement. Analytic hierarchy process (AHP) is utilized in this study to evolve such a model. Each step in the model was derived by group-discussions andbrainstorming sessions among experienced clinicians and managers. This tool was applied to two tertiary care teaching hospitals in Barbados and India. The model enabled identification of specific areas where neither hospital performed very well, and helped to suggest recommendations to improvethose areas. AHP is recommended as a valuable tool to measure the process-based performance of multispecialty tertiary care hospitals.

Futility-of-care decisions in the treatment of moribund intensive care patients in a developing country.

PURPOSE: To analyze the characteristics of moribund patients in a surgical intensive care unit (ICU) and highlight the dilemmas inherent in treating such patients. METHODS: Data on all patients admitted to the surgical ICU during the period of three years from July 1999 to June 2002 were collected prospectively. Data were collected on very ill patients who died, in whom it appeared obvious that treatment could not have improved their condition and whose death could have been anticipated. The case notes were subjected to further analysis to determine the difficulties encountered in managing patients whose therapy was considered to be futile. RESULTS: Of 662 admissions, 100 (15.1%) died and 30 (4.5%) patients were treated aggressively, even after a prognosis which reflected futile treatment. The overall mean length of stay for survivors was 7.5 +/- 9.0 [standard deviation (SD)] days and that for the non-survivors was 12.8 +/- 18.1 (SD; P < 0.001). The cost incurred for the treatment of non-survivors was significantly higher than that for the surviving patients. The factors relating to the decisions to continue futile therapy were age of the patient, legal considerations, family wishes and differing opinions between treating physicians. CONCLUSION: Consideration of futility during end-of-life care did not receive adequate attention in this unit which incurred additional human and material resources.

Spectrum of microbes and antimicrobial resistance in a surgical intensive care unit, Barbados.

BACKGROUND: To survey the epidemiologic findings of infections and antibiotic resistance patterns in the surgical intensive care unit (ICU) of a tertiary care university teaching hospital. METHODS: The microbiologic culture-sensitivity reports of patients admitted to a surgical ICU were prospectively studied for 6 months each of 3 consecutive years. The antibiotic usage for these patients also was studied concurrently. Reports from general surgical wards for 6 months of 1 year also were analyzed for comparison. The common specimens assayed microbiologically were tracheal aspirate, urine, blood, wound swabs, invasive catheter tips, and screening swabs for methicillin-resistant Staphylococcus aureus. RESULTS: The organisms reported were Enterobacteriaceae, Pseudomonas species, S aureus, and enterococci. Organisms were highly resistant to amoxicillin and first-generation cephalosporins because of the wide use of these drugs in the hospital. Pseudomonas species showed a 25% increase in resistance to piperacillin-tazobactam and an 18% increase to ciprofloxacin, which was correlated with the increased use of these antimicrobial agents (82% and 200% increases, respectively) in the unit during the 3 years. There was no increase in the resistance to ceftazidime because it is used less often. The resistance to ciprofloxacin, piperacillin-tazobactam, and ceftazidime was significantly greater in the ICU than in the general surgical wards in the same study period. CONCLUSIONS: The study provided data of antimicrobial resistance in a developing country with tourism as the main industry for epidemiologic comparison with other countries.

Renal transplantation from living related donors in Barbados

The results of 10 living donor (LRD) renal transplants performed in Barbados during the period 1987 to 1997 are reported. The donors were four mothers, three fathers, two brothers and an uncle. The six female and four male recipients were 14 to 36 years of age. Four recipients displayed delayed graft function (DFG), ie, failure to produce more than 1.0 L of urine in the first 24 hours and/or failure to reduce plasma creatinine by more than 50 percent in the first 48 post-operative hours. Two of these grafts were lost due to thrombosis of the allograft anastomisis; one patient successfully resumed haemodialysis therapy following transplant nephrectomy but the other died from the respiratory distress syndrome three days after transplantation. Of the remaining two patients with DGF, one showed impaired function at one year and subsequently lost the allograft at ten years post-transplantation from chronic rejection, the other has "normal" renal function five year post-transplantation. One other patient died in the early post-operative period, from a cerebral haemorrhage due to uncontrolled hypertension. Five of the allografts were functioning five years after transplantation (mean plasma creatinine = 169.2 umols/l); one has a plasma creatinine of 112 umols/l at one year and another has a plasma creatinine of 300 umols/l eight months after transplantation. This experience shows that the infrastructure to support LRD renal transplants is established in Barbados and can be used to supplement renal replacement initiatives in Barbados and in neighbouring Eastern Caribbean states.(AU)

Weather as a predictor of the frequency of asthmatic attacks in Barbados - abstract

Daily data on asthmatic patients seen in the Accident and Emergency Department of the Queen Elizabeth Hospital for the years 1983 and 1989-1991, and corresponding daily data for the meterological variables of wind speed, relative humidity (0800 hr), vapour pressure and minimum and maximum temperatures were analysed to determine the statistical relationships that might exist. The results show positive correlation between asthma attacks and relative humidity and vapour pressure, and negative correlations for the wind speed. The data also show the existence of a seasonal variation in asthmatic attacks. It is suggested that this variation is due to the transport of aero-allergens into Barbados through the trade winds (AU)

Total intravenous anaesthesia for day-care surgery using diclofenac for analgesia - abstract

The trend in modern surgery is to do more and more cases as "Day Care". This approach saves money by promoting the efficient use of available bed space and the time of hospital-based health professionals. The main objective of the anaesthetic technique is to produce conditions satisfactory to surgeon and patient, using agents that allow for the safe and rapid discharge of the patient from the hospital. Inhalation techniques with halothane and by using narcotics for post-operative analgesia are the standard techniques used in the Queen Elizabeth Hospital in Barbados. However, studies have shown that the combination of various narcotics such as Fentanyl and Alfentanyl for analgesia in total intravenous anaesthesia techniques, using continuous intravenous Propofol, will produce satisfactory anaesthesia for many types of surgical procedures with short recovery periods. Substitution of analgesics in the non-steroidal anti-flammatory drug group (NSAIDs), in combination with Propofol, offers the opportunity for avoiding the side-effects of narcotics. Accordingly, the effectiveness of total intravenous anaesthesia, using Propofol with the NSAID Diclofenac for analgesia in patients undergoing laparoscopic gynaecological surgery as day-care patients was compared with the standard inhalation anaesthetic technique, using a narcotic (Fetanyl) analgesia. The thirty-eight female patients studied were induced with Propofol (2.5 mg/kg-1) for muscle relaxation. Nineteen received Fentanyl (1-1.5 ægm kg-1) i.v. immediately prior to induction and anaesthesia was continued, using 50 percent nitrous oxide (2-1 min-1) in oxygen and Halothane (1-1.5 percent). The other nineteen received Diclofenac (75 mg i.m.) one hour before surgery and anaesthesia was continued with an infusion of Propofol, using an Ohmeda 9000 syringe pump at 12 mg. kg-1.h-1. Conditions for surgery were satisfactory in both groups and there was no signidicant difference in the degree of post-operative analgesia or the time to awaken under anaesthesia and all patients said they would be happy to have the anaesthetic technique used again. However, the total intravenous technique is expensive and therefore its use is recommended only when inhalation methods or the use of narcotics in undesirable (AU)

Inspiratory valve malfunction in a circle system: pitfalls in capnography

Capnography is a useful technique in monitoring the integrity of anaesthetic equipment such as the malfunctioning of unidirectional valves in circle system. However, the lack of a precise mechanism in existing capnographs to identify the start of inspiration and the beginning of expiration in the capnograms, makes the analysis of the carbon dioxide waveforms during inspiration difficult and thus results in inaccurate assessement of rebreathing. We report a case where, during the malfunction of the inspiratory unidirectional valve in the circle system, the capnograph failed to detect the presence of substantial rebreathing. Critical analysis of the capnogram recorded during the malfunction revealed that there was substantial rebreathing which was underestimated by the capnograph as it reports only the lowest CO2 concentration rebreathed during inspiration in such abnormal situations.(AU)

Anaesthesia without nitrous oxide

Nitrous oxide has a long history of successful use in inhalational anaesthesia. Nevertheless questions are being raised over possible deleterious effects which may complicate its routine use. As more potent volatile agents have become available, compressed air/oxygen mixtures are gradually replacing nitrous oxide as a carrier gas in inhalational anaesthesia. We recommend that compressed air be installed on all anaesthetic machines and that in future, machines be designed so as to make it impossible to administer both nitrous oxide and air simultaneously. (Summary)

Potassium and glucose tolerance in Barbadian hypertensives, treated with thiazides - abstract

This study was designed to assess the metabolic complications of thiazide use in black Barbadian hypertensives, and in particular the relationship between plasma potassium and glucose tolerance, including glycated haemoglobin (HbA1C). Patients attending the QEH Hypertension Clinic, whose blood pressure was controlled on a thiazide diuretic and no more than two other drugs, and who gave informed consent, were randomly assigned to one of four thiazide regimes (plus their other usual drugs): bendrofluazide (B) 5mg, bendrofluazide 5 mg+ potassium (K) 39 meq daily, triamterene/hydrochlorothiazide (T/H), or amiloride/hydrochlorothiazide (A/H). Forty patients completed one-year follow-up. There were no significant differences in any metabolic variables or bloodpressures at baseline. At one year, significant differences were seen for plasma potassium between patients on B and on B + K (p<0.05), between those on B and on T/H (p 0.01) and between the T/H and A/H groups (p<0.05), using Student 't' test. When compared by analysis of variance (ANOVA), these differences were again significant (F + 3.62, p + 0.03). When data of all 40 subjects for the baseline assessment and at one year were analysed as a group, there was a strong negative correlation between change in plasma potassium (K6 - K1), and change in glycated haemoglobin (HbA1C 6 - HbA1C 1) (r = 0.62, p = < 0.01). This is the first time that thiazide-induced changes in plasma potassium, and correction of hypokalaemia have been shown to be correlated withn glycated haemoglobin, and that this relationship applies across the whole range of potassium values. If these results can be confirmed in other study populations, then perhaps thiazides can be safely used without inducing glucose intolerance or diabetes, as long as effective potassium supplementation is achieved. This has far-reaching implications for the cost-effective treatment of hypertension in the Caribbean, and other developing countries(AU)

Caesarean sections in Barbados (1979-1985) - abstract

A retrospective analysis of Caesarean Sections (CS) performed at the Queen Elizabeth Hospital, Barbados during the period 1979 to 1985 was done to determine the rate of CS. The medical records of all CS done at the hospital during that period were reviewed and indications for the procedure were noted. Results are shown in the table given. The indications which contributed most to the increase in CS rate were previous CS and breech presentations. Over the 7-year period, the percentage of breech presentations which were managed with CS increased from 32 per cent to 85 per cent, and the corresponding values for previous CS were 60 per cent and 91 per cent, respectively (AU)

The supply of oxygen to the Queen Elizabeth Hospital - abstract

The Queen Elizabeth Hospital gets its oxygen supplies as compressed gas in cylinders from the sole producer in Barbados. Expenditure on oxygen will have risen to B$500,000 per annum in 1988. The rising use and cost of oxygen, stimulated the Queen Elizabeth Hospital Administration to consider generation of its oxygen. A cost analysis revealed that by doing this, it may be possible to save B$250,000 in expenditure on oxygen annually. An oxygen concentrator was installed at the Hospital and put into use in November, 1988 (AU)

Propofol: a new intravenous anaesthetic

Propofol, a new intravenous anaesthetic induction agent, was evaluated on female patients undergoing short surgical procedures. The incidence of pain on injection, apnoea following injection, and the fall of systolic and diastolic blood pressure levels, was similar to that previously reported. There was no significant fall in pulse rate. The quality of anaesthesia during induction was good in all patients who reported they would be happy to receive the drug again (AU)

Hepatitis B antibody levels in health-care workers of a large general hospital in Barbados

In order to assess the immune status to Hepatitis B in a general hospital population in the Caribbean, we studied the antibody level to Hepatitis B surface antigen (anti HBs) and to core antigen (anti HBc) in 90 health-care workers at the Queen Elizbeth Hospital in Barbados, West Indies. There was one asymptomatic carrier with Hepatitis B antigen (HBsAg). Thirteen (14.6 percent) of the remaining 89 possessed anti HBs; 10 of these (11.2 percent) were considered to be immune, and three non-immune. The 10 immune subjects were also positive for anti HBc whereas the other three "non-immune" positives were not. One person in the study had strong anti HBc immunity but was negative for anti HBs. There appeared to be no relationship between immunity and age, sex, profession or duration of work years. From the study, 76 individuals (84 percent were easily identified as being susceptible to Hepatitis B and were candidates for HBV vaccine. (AU)

Should air-oxygen nitrous oxide-oxygen in general anaesthesia?

The use of compressed air-oxygen mixtures to replace nitrous oxide-oxygen in general anaesthesia was investigated in 378 patients. There were neither prolongations of recovery time nor instances of awareness under anaesthesia. The cost of general anaesthesia using compressed air-oxygen was about half that for nitrous oxide-oxygen mixtures.(AU)

Intravenous lignocaine prior to intubation effect on rhythm and changes in heart rate and rate pressure product - abstract

Tracheal intubation is frequently associated with occurrence of cardiac dysrhythmias and is almost always accompanied by increases in systolic and diastolic blood pressure. In some instances, these cardiovascular changes may lead to disastrous complications. A prospective study was undertaken to evaluate the efficacy of intravenous lignocaine prior to intubation in blunting the cardiovascular responses to intubation in a West Indian population. Seventy-five clinically fit patients (age range 20 -40 years, mean 27.5) were included. They were divided into 3 groups as follows: Group A: received 1 mg/kg lignocaine hydrochloride as I.V. bolus dose 1 min prior to induction of anaesthesia. Group B: - received 2mg/kg lignocaine, and Group C: - No ligocaine (control). Parameters recorded were heart rate (HR), cardiac rhythm (ECG), systolic and diastolic bloodpressure (BP), and (heart) Rate - (systolic) pressure product (RPP). These were measured at the following times: 1. Prior to induction of anaesthesia, 2. During laryngoscopy and intubation, 3: 1 min following intubation and 4: 5 mins following intubation. After the pre-induction parameters were recorded, lignocaine was given in 1 and 2 mg/kg doses in groups A & B patients. One minute following lignocaine, patients were anaesthetised using standard techique and the trachea was intubated. All parameters were again recorded, lignocaine was given in 1 and 2 mg/kg doses in groups A percent B patients. One minute following lignocaine, patients were anaesthetised using standard technique and the trachea was intubated. All parameters were again recorded at the stated times. Both the HRs and RPPs increased significantly in all the 3 groups following intubation. The increase in group B (2mg/kg) was significantly lower than in the control group. Group A patients (1mg/kg) did not show any consistent difference, statistically, compared to the control group. The incidence of dysrhythmias was 64 percent in the control group, 32 percent in group A patients (1mg/kg) and 12 percent in group B (2mg.kg). Seventy per cent of all dysrhythmias occurred at the time of laryngoscopy and intubation, consisting mainly of supra-ventricular and ventricular ectopics. Intravenous lignocaine prior to intubation decreases the incidence of dysrhythmias and also decreases the degree of rise in HRs and RPPs. Lignocaine at a dose of 2 mg/kg is better than a dose of 1 mg/kg (AU)

Can compressed air/oxygen replace nitrous oxide/oxygen in general anaesthesia? a preliminary survey - abstract

The use of compressed air/oxygen mixtures to replace nitrous oxide/oxygen in general anaesthesia is investigated in 378 patients. There was no prolongation of recovery time nor instances of awareness under anaesthesia. The cost of general anaesthesia, using compressed air/oxygen mixtures was BDS$10.05 per patient while the cost of using nitrous oxide/oxygen mixtures was BD$20.11 per patient (AU)

The incidence and important of post-suxamethonium pain in Barbadian patients

A survey of the incidence of post-suxamethonium muscle pain and/or stiffness (PSPS) following its administration for muscle relaxation during anaesthesia was carried out at the Queen Elizabeth Hospital in Barbados. It revealed a much lower overall incidence of PSPS (10.9 per cent) than usually reported. The incidence of severe PSPS of 2.52 per cent was also lower than in other reports. This may suggest a geographical or population difference. The relationship of PSPS to such factors as the degree of fasciculation, postoperative activity, type of operation, dose of suxamethonium, serum cholinesterase levels and dibucaine numbers and the use of the thiopentone and non--depolarising relaxants was also investigated. No relationship could be found. The predominance of PSPS in women between 21 and 30 years of age and those over 71 years of age found in Barbados merits further study. (AU)