Perioperative Quality Initiative (POQI) consensus statement on fundamental concepts in perioperative fluid management: fluid responsiveness and venous capacitance.

BACKGROUND: Optimal fluid therapy in the perioperative and critical care settings depends on understanding the underlying cardiovascular physiology and individualizing assessment of the dynamic patient state. METHODS: The Perioperative Quality Initiative (POQI-5) consensus conference brought together an international team of multidisciplinary experts to survey and evaluate the literature on the physiology of volume responsiveness and perioperative fluid management. The group used a modified Delphi method to develop consensus statements applicable to the physiologically based management of intravenous fluid therapy in the perioperative setting. DISCUSSION: We discussed the clinical and physiological evidence underlying fluid responsiveness and venous capacitance as relevant factors in fluid management and developed consensus statements with clinical implications for a broad group of clinicians involved in intravenous fluid therapy. Two key concepts emerged as follows: (1) The ultimate goal of fluid therapy and hemodynamic management is to support the conditions that enable normal cellular metabolic function in order to produce optimal patient outcomes, and (2) optimal fluid and hemodynamic management is dependent on an understanding of the relationship between pressure, volume, and flow in a dynamic system which is distensible with variable elastance and capacitance properties.

Stratification of inflammatory bowel disease outpatients by disease activity and risk of complications to guide out-of-hospital monitoring: a patient-centred quality improvement project.

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic relapsing-remitting condition affecting 600 000 people in the UK. Traditionally, patients attend outpatient clinics for monitoring regardless of their symptoms or risk of developing complications. This can lead to a mismatch between need and access: patients in remission given elective appointments displace those in need of urgent specialist attention. Novel initiatives implemented in the UK to improve outpatient monitoring have often required a well-maintained patient registry, empowered patients and significant information technology support. DESIGN AND STRATEGY: In this large-scale quality improvement project at St Mark's Hospital, a tertiary centre for IBD, we stratified over 1000 patients attending three non-complex IBD clinics over 12 months according to disease activity and risk profile. The aim was to offer a choice and subsequently transfer 50% of eligible patients to specialist nurse-led telephone clinics and demonstrate non-inferior satisfaction levels to existing outpatient follow-up. We also sought to ensure there was timely access to a newly established rapid access clinic for patients requiring urgent specialist attention.A core project team consisting of healthcare professionals, patients and quality improvement scientists met regularly. The team tested and scaled up interventions using 'Plan-Do-Study-Act' cycles within the 'Model for Improvement' framework and analysed data continuously using statistical process charts. RESULTS: Over 12 months, the average number of eligible patients transferred to telephone clinics rose from 17.6% (42/239) using a questionnaire method to 59.3% (73/123) using active discussion in clinic. Patient satisfaction scores remained high and non-inferior to baseline scores in face-to-face clinics. The median waiting time to be seen in the rapid access clinic was 6.5 days. CONCLUSION: This is the first published study to report on the successful stratification of patients with IBD based on disease activity and risk of complications to create a more responsive, sustainable and patient-centred model for IBD monitoring.

A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications.

Background: Dehydration appears prevalent, costly and associated with adverse outcomes. We sought to generate consensus on such key issues and elucidate need for further scientific enquiry. Materials and methods: A modified Delphi process combined expert opinion and evidence appraisal. Twelve relevant experts addressed dehydration's definition, objective markers and impact on physiology and outcome. Results: Fifteen consensus statements and seven research recommendations were generated. Key findings, evidenced in detail, were that there is no universally accepted definition for dehydration; hydration assessment is complex and requires combining physiological and laboratory variables; "dehydration" and "hypovolaemia" are incorrectly used interchangeably; abnormal hydration status includes relative and/or absolute abnormalities in body water and serum/plasma osmolality (pOsm); raised pOsm usually indicates dehydration; direct measurement of pOsm is the gold standard for determining dehydration; pOsm >300 and ≤280 mOsm/kg classifies a person as hyper or hypo-osmolar; outside extremes, signs of adult dehydration are subtle and unreliable; dehydration is common in hospitals and care homes and associated with poorer outcomes. Discussion: Dehydration poses risk to public health. Dehydration is under-recognized and poorly managed in hospital and community-based care. Further research is required to improve assessment and management of dehydration and the authors have made recommendations to focus academic endeavours. Key messages Dehydration assessment is a major clinical challenge due to a complex, varying pathophysiology, non-specific clinical presentations and the lack of international consensus on definition and diagnosis. Plasma osmolality represents a valuable, objective surrogate marker of hypertonic dehydration which is underutilized in clinical practice. Dehydration is prevalent within the healthcare setting and in the community, and appears associated with increased morbidity and mortality.

The use of crystalloids in traumatic brain injury.

Fluid therapy is one of the most important treatments in patients with traumatic brain injury (TBI) as both hypo- and hypervolaemia can cause harm. The main goals of fluid therapy for patients with TBI are to optimize cerebral perfusion and to maintain adequate cerebral oxygenation. The avoidance of cerebral oedema is clearly essential. The current weight of evidence in the published literature suggests that albumin therapy is harmful and plasma substitutes have failed to demonstrate superiority over crystalloids solutions. Crystalloids are the most common fluids administered in patients with TBI. However, differences in their composition may affect coagulation and plasma tonicity and acid-base homeostasis. The choice of the ideal crystalloid fluid in TBI should be made based on tonicity, type of buffer used and volume status. Hypotonic fluids buffered with substances altering blood coagulation should be avoided in clinical practice. The prescriber remains faced with choices about the tonicity and pH buffering capability of fluid therapy, which we review here.

Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital.

OBJECTIVES: Reliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge. SETTING: An acute 400-bedded teaching hospital in London, UK. PARTICIPANTS: The effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18 months. INTERVENTIONS: Quality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives. RESULTS: Statistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients' discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems. CONCLUSIONS: New processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers.

Understanding what matters to patients - identifying key patients' perceptions of quality.

OBJECTIVES: To demonstrate a statistical method to enable the identification of key drivers of quality from a patient perspective that can be used by service providers to help drive improvement. DESIGN: Cross-tabulation, Chi-square analysis and Cramer's V calculation using SPSS software of NHS Inpatient Surveys 2006 and 2007. SETTING: The NHS Inpatient Survey is a standardized survey designed by the Picker Institute conducted on a sample of patients across all acute care hospital trusts in England. PARTICIPANTS: The surveys (available from the UK Data Archive) provide anonymized patient data for over 77,000 patients in 2006 and 72,000 patients in 2007. MAIN OUTCOME MEASURES: Cramer's V score testing associations between patient ratings on multiple components of care and ratings on the overall quality of care. RESULTS: Of the 58 questions analysed, some questions correlate more strongly with overall satisfaction of care than others and there is strong agreement of results over the two years. Of the top 20 rated components, communication (both between professionals and between professionals and patients) and trust engendered by that communication is a recurring theme. CONCLUSIONS: Hospital trusts are required to develop quality indicators and collate detailed feedback from patients in addition to the annual inpatient survey to measure these. To make best use of resources, additional data collection should focus on those aspects of care of most importance to patients locally. This analysis demonstrates a statistical technique that can help to identify such priority areas by showing those aspects of care most strongly associated with the overall rating of care. The analysis uses national level data to demonstrate how this can be achieved. This shows the importance to patients of being treated with dignity and respect, and good communication between staff and between staff and patients.

Law and medical ethics in organ transplantation surgery.

This article in the series describes how UK law and medical ethics have evolved to accommodate developments in organ transplantation surgery. August committees have formulated definitions of the point of death of the person which are compatible with the lawful procurement of functioning vital organs from cadavers. Some of the complexities of dead donor rules are examined. Live donors are a major source of kidneys and the laws that protect them are considered. Financial inducements and other incentives to donate erode the noble concept of altruism, but should they be unlawful?

Communication of end-of-life decisions in European intensive care units.

OBJECTIVE: To examine end-of-life (EOL) practices in European ICUs: who makes these decisions, how they are made, communication of these decisions and questions on communication between the physicians, nurses, patients and families. DESIGN: Data collected prospectively on EOL decisions facilitated by a questionnaire including EOL decision categories, geographical regions, mental competency, information about patient wishes, and discussions with patients, families and health care professionals. SETTING: 37 European ICUs in 17 countries. PATIENTS: ICU physicians collected data on 4,248 patients. RESULTS: 95% of patients lacked decision making capacity at the time of EOL decision and patient's wishes were known in only 20% of cases. EOL decisions were discussed with the family in 68% of cases. Physicians reported having more information about patients' wishes and discussions in the northern countries (31%, 88%) than central (16%, 70%) or southern (13%, 48%) countries. The family was more often told (88%) than asked (38%) about EOL decisions. Physicians' reasons for not discussing EOL care with the family included the fact that the patient was unresponsive to therapy (39%), the family was unavailable (28%), and the family was thought not to understand (25%). CONCLUSIONS: ICU patients typically lack decision-making capacity, and physicians know patients' wishes in only 20% of EOL decisions. There were regional differences in discussions of EOL decisions with families and other physicians. In European ICUs there seems to be a need to improve communication.

End-of-life practices in European intensive care units: the Ethicus Study.

CONTEXT: While the adoption of practice guidelines is standardizing many aspects of patient care, ethical dilemmas are occurring because of forgoing life-sustaining therapies in intensive care and are dealt with in diverse ways between different countries and cultures. OBJECTIVES: To determine the frequency and types of actual end-of-life practices in European intensive care units (ICUs) and to analyze the similarities and differences. DESIGN AND SETTING: A prospective, observational study of European ICUs. PARTICIPANTS: Consecutive patients who died or had any limitation of therapy. INTERVENTION: Prospectively defined end-of-life practices in 37 ICUs in 17 European countries were studied from January 1, 1999, to June 30, 2000. MAIN OUTCOME MEASURES: Comparison and analysis of the frequencies and patterns of end-of-life care by geographic regions and different patients and professionals. RESULTS: Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%) had limitations of treatments (10% of admissions). Substantial intercountry variability was found in the limitations and the manner of dying: unsuccessful cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range, 0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range, 0%-19%). Shortening of the dying process was reported in 7 countries. Doses of opioids and benzodiazepines reported for shortening of the dying process were in the same range as those used for symptom relief in previous studies. Limitation of therapy vs continuation of life-sustaining therapy was associated with patient age, acute and chronic diagnoses, number of days in ICU, region, and religion (P<.001). CONCLUSION: The limiting of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors. Although shortening of the dying process is rare, clarity between withdrawing therapies and shortening of the dying process and between therapies intended to relieve pain and suffering and those intended to shorten the dying process may be lacking.