Protocol for a stepped wedge cluster randomized quality improvement project to evaluate the impact of medical safety huddles on patient safety.

Introduction: Physician engagement is crucial for furthering patient safety and quality improvement within healthcare organizations. Medical Safety Huddles, which are physician-specific huddles, is a novel way to engage physicians with patient safety and may reduce adverse events experienced by patients. We plan to conduct a multi-center quality improvement (QI) initiative to implement and evaluate Medical Safety Huddles. The primary objective is to determine the impact of the huddles on adverse events experienced by patients. Secondary objectives include assessing the impact of the huddles on patient safety culture and physician engagement, and a process evaluation to assess the fidelity of implementation. Methods: This stepped wedge cluster randomized study will be conducted at four academic inpatient hospitals over 19 months. Each site will adapt Medical Safety Huddles to its own practice context to best engage physicians. We will review randomly selected patient charts for adverse events. Generalized linear mixed effects regression will be used to estimate the overall intervention effect on adverse events. Process measures such as physician attendance rates and number of safety issues raised per huddle will be tracked to monitor implementation adherence. Conclusion: Medical Safety Huddles may help healthcare organizations and medical leaders to better engage physicians with patient safety. The project results will assess the fidelity of implementation and determine the impact of Medical Safety Huddles on patient safety.

Allergic contact dermatitis and eosinophilia in association with a hemodialysis cannula.

After starting daily hemodialysis (HD) therapy, 2 patients experienced pruritic, erythematous, papular eruptions at their arteriovenous fistula sites. Both patients also developed systemic eosinophilia, with eosinophil counts from 1.0 to 4.4 x 10(9) . In all other respects, the patients were well and both had a subjective improvement in their quality of life. Results of initial investigations to rule out the possibility of parasites, collagen vascular disease, and myeloproliferative disorders were negative in 1 patient. Subsequent patch testing in both patients was positive for allergic contact dermatitis secondary to the epoxy resin used in their blunt HD needles.

What is the risk of bacterial meningitis in infants who present to the emergency department with fever and pyuria?

OBJECTIVE: To determine the rate of bacterial meningitis among febrile infants in the emergency department (ED) who have pyuria detected in an initial catheterized urine specimen. METHODS: This retrospective chart review, conducted at the Hospital for Sick Children, Toronto, Ont., involved all children aged 0 to 3 months who presented to the ED with fever and pyuria (>/=10 white blood cells/mm(3)) over a 3-year period. Cerebrospinal fluid (CSF) was evaluated using standard methods, and the rate of meningitis in children with pyuria was determined. RESULTS: The study sample included 211 infants with fever and pyuria -- 79 of these under 1 month of age. Eighty-one percent (171/211) had positive urine cultures, and 143 underwent lumbar puncture to rule out meningitis. Of these, 140 CSF samples were culture negative and 3 grew coagulase negative Staphylococcus -- 2 because of contamination and 1 because of a ventriculo-peritoneal shunt infection. Both children with CSF contamination grew Escherichia coli in the urine. The rate of bacterial meningitis in the study sample was 0% (95% confidence interval, 0%-2.6%). CONCLUSIONS: In this study of febrile children under 90 days of age with fever and pyuria, the incidence of concurrent meningitis was 0%. This suggests that recommendations for mandatory lumbar puncture in such children should be reconsidered. However, until larger prospective studies define a patient subset that does not require CSF analysis, it is prudent to rule out meningitis, administer parenteral antibiotics for urinary tract infection, and admit for close observation.

Antipyretic efficacy and safety of ibuprofen and acetaminophen in children.

OBJECTIVE: To evaluate the antipyretic effects and safety of ibuprofen compared with acetaminophen in febrile children. DATA SOURCES: Searches of MEDLINE (1966-November 2003) and EMBASE (1988-November 2003) were conducted using the terms ibuprofen and acetaminophen. Bibliographies of selected articles were reviewed. DATA SYNTHESIS: Ibuprofen was significantly more effective than acetaminophen in reducing fever after a single dose. Ibuprofen was found to be more effective after 6 hours, but not after a longer period of time. Studies with multiple doses have also failed to show that one drug is better than the other. CONCLUSIONS: The efficacy and effectiveness of acetaminophen and ibuprofen in their recommended dosages are similar, with slightly more beneficial effects shown with ibuprofen.