A detailed analysis of theatre training activity in a UK teaching hospital.
(65/2039)
We examined the placement of anaesthetists in our department over a 2 yr period. Data were collected from an in-theatre system to provide details of caseload and supervision for 34,856 operations. There was wide variation between anaesthetic sub-specialties with overall supervision levels of 35% of cases for senior house officers (SHOs) and 32% for specialist registrars (SpRs). The consultant data showed the size and areas of teaching reserve in the department. We then examined individual logbooks in order to validate our data, and departmental rotas to put these data into perspective with previous attempts to quantify trainee supervision. Supervision data derived from the rota allocations showed that 86% of SHO lists and 62% of SpR lists were scheduled to be supervised. This study has described our training activity and facilitated departmental changes, as well as highlighting the need for great care in interpreting trainee supervision data acquired from different sources, particularly when comparisons are being made. (+info)
Prevalence of beta-lactamases among 1,072 clinical strains of Proteus mirabilis: a 2-year survey in a French hospital.
(66/2039)
beta-Lactam resistance was studied in 1,072 consecutive P. mirabilis clinical strains isolated at the Clermont-Ferrand teaching hospital between April 1996 and March 1998. The frequency of amoxicillin resistance was 48.5%. Among the 520 amoxicillin-resistant isolates, three resistance phenotypes were detected: penicillinase (407 strains [78.3%]), extended-spectrum beta-lactamase (74 strains [14. 2%]), and inhibitor resistance (39 strains [7.5%]). The penicillinase phenotype isolates were divided into three groups according to the level of resistance to beta-lactams, which was shown to be related to the strength of the promoter. The characterization of the different beta-lactamases showed that amoxicillin resistance in P. mirabilis was almost always (97%) associated with TEM or TEM-derived beta-lactamases, most of which evolved via TEM-2. (+info)
Enterococcal glycopeptide resistance at an Italian teaching hospital.
(67/2039)
Two thousand one hundred and thirteen strains of enterococci isolated at Pisa General Hospital in 1998 were analysed retrospectively to determine their glycopeptide resistance. Of all the microorganisms isolated in this period, 14.7% were enterococci (1405 Enterococcus faecalis, 19 Enterococcus faecium, six Enterococcus avium and 683 Enterococcus spp.). Two hundred and thirty (10.8%) of these enterococci were resistant or demonstrated reduced susceptibility to vancomycin and/or teicoplanin. The highest rate of resistance was found in outpatient enterococcal strains isolated from the urogenital tract. The frequency of enterococcal glycopeptide resistance at Pisa Hospital is higher than that reported from other areas of Italy. (+info)
Management of acute childhood asthma: a prospective multicentre study.
(68/2039)
Children with acute asthma account for a significant proportion of paediatric hospital admissions, and clear guidelines exist for their care. The aim of this study was to determine their management in the UK. Over 1 year (February 1995 to January 1996), children aged 1-14 yrs admitted with acute asthma were studied in both teaching and district general hospitals. An admission pro forma was used to collect data prospectively, with a computer-based information management system for the input of admissions in each centre. Ten centres collected data prospectively, with 1,578 admissions involving 1,352 children (median age 3.6 yrs). Sixty two per cent of children were <5 yrs of age. Sixty three per cent of admissions had initial arterial oxygen saturation (Sa,O2) recorded, and, in those older than 5 yrs, 36% had their initial peak expiratory flow rate recorded. Systemic steroids were given to 78%. An initial Sa,O2 of <92% was associated with a longer stay in hospital, and also with intravenous treatment. Preventative treatment increased from 42% on admission to 53% on discharge. The rates of documented education were low. This is the largest UK study following publication of national guidelines and shows that there is still room for improvement in the management of children admitted with acute asthma. (+info)
A 12-month review of autopsies performed at a university-affiliated teaching hospital in Hong Kong.
(69/2039)
OBJECTIVE: To review the autopsies performed at a university-affiliated teaching hospital over a 12-month period. DATA SOURCES: Records of autopsies performed at a university-affiliated teaching hospital during 1997, and Medline literature search (1966-1998). STUDY SELECTION: The key words used in the literature search were 'autopsy' and 'audit'. DATA EXTRACTION: Data were extracted and analysed by the authors. Any discrepant cases (in which the final diagnoses were either unexpected or not made before death) were identified from the hospital records. DATA SYNTHESIS: Interest in autopsy results has increased, owing to the greater emphasis on medical audit and quality assurance procedures. Of the yearly total of 403 autopsies, 332 cases were reviewed; the discrepancies found were classified as either major or minor, according to their effect on the clinical outcome. The major and minor discrepancy rates were 23% and 9%, respectively. In 2% of cases, the cause of death was due to complications resulting from surgical intervention. These discrepancy rates were comparable to the figures quoted in the literature. CONCLUSION: Autopsy is a valid medical quality-assurance mechanism in Hong Kong. (+info)
The quality of early-stage breast cancer care.
(70/2039)
OBJECTIVE: To assess whether recent practice has improved, the authors created detailed, evidence-based guidelines and assessed the quality of early-stage breast cancer care at four hospitals in the metropolitan New York area. SUMMARY BACKGROUND DATA: Adjuvant treatments for early-stage breast cancer have been shown to improve health and longevity. However, reports from the 1980s showed marked underuse of these therapies. METHODS: All 723 women with early-stage breast cancer who had a definitive surgical procedure at four participating hospitals in the Mount Sinai-NYU Health System between April 1994 and August 1996 were included. Inpatient and outpatient records were abstracted. RESULTS: Fifty-nine percent of women underwent breast-conserving surgery, of whom 81% received radiation therapy. Hospital-specific radiation therapy rates varied from 69% to 87%. Seventy-eight percent of women with stage 1B or greater cancer received systemic treatment, with hospital-specific rates varying from 71% to 86%. Between 18% and 33% of women who could have benefited from local or systemic adjuvant treatments did not receive them. The risk of not getting a beneficial adjuvant treatment varied more than twofold by the hospital where the breast cancer surgery was performed. CONCLUSIONS: The hospital where breast cancer surgery is performed is associated with the likelihood that women receive effective local and systemic adjuvant treatments. Surgeons and members of hospital quality improvement programs should encourage multidisciplinary approaches to breast cancer care. (+info)
Changing the site of delivery of thrombolytic treatment for acute myocardial infarction from the coronary care unit to the emergency department greatly reduces door to needle time.
(71/2039)
OBJECTIVE: To quantify the change in door to needle time when delivery of thrombolytic treatment of acute myocardial infarction was changed from the coronary care unit to the emergency department. DESIGN: A comparative observational study using prospectively collected data. SETTING: Coronary care unit and emergency department of an Australian teaching hospital. PARTICIPANTS: 89 patients receiving thrombolysis in coronary care unit between June 1994 and January 1996, and 100 patients treated in the emergency department between April 1997 and May 1998. INTERVENTIONS: From April 1997, by agreement between cardiology and emergency medicine, all patients with acute myocardial infarction receiving thrombolysis were treated by emergency physicians in the emergency department. MAIN OUTCOME MEASURE: Door to needle time measured from time of arrival at the hospital to start of thrombolysis. Other outcomes included pain to needle time and mortality. RESULTS: Median door to needle times were less for patients treated in the emergency department than in the coronary care unit (37 minutes, 95% confidence interval (CI) 33 to 44 v 80 minutes, 95% CI 70 to 89, respectively; p < 0.0001). Door to needle time was under 60 minutes in 83% of emergency department patients and 26% of coronary care unit patients (57% difference, 95% CI 45% to 69%; p < 0.0001). Median pain to needle time was less for emergency department patients than for coronary care unit patients (161 minutes, 95% CI 142 to 177 v 195 minutes, 95% CI 180 to 209; p = 0.004); times of less than 90 minutes occurred in 18% of emergency department patients v 1% of coronary care unit patients (17% difference, 95% CI 9% to 25%; p < 0.05). Overall mortality was similar in patients treated in the emergency department and the coronary care unit. CONCLUSIONS: With a collaborative interdepartmental approach, thrombolytic treatment of acute myocardial infarction was more rapid in the emergency department, without compromising patient safety. This should improve the outcome in patients with infarcts treated with thrombolytic agents. (+info)
Confidential clinician-reported surveillance of adverse events among medical inpatients.
(72/2039)
BACKGROUND: Although iatrogenic injury poses a significant risk to hospitalized patients, detection of adverse events (AEs) is costly and difficult. METHODS: The authors developed a confidential reporting method for detecting AEs on a medicine unit of a teaching hospital. Adverse events were defined as patient injuries. Potential adverse events (PAEs) represented errors that could have, but did not result in harm. Investigators interviewed house officers during morning rounds and by e-mail, asking them to identify obstacles to high quality care and iatrogenic injuries. They compared house officer reports with hospital incident reports and patients' medical records. A multivariate regression model identified correlates of reporting. RESULTS: One hundred ten events occurred, affecting 84 patients. Queries by e-mail (incidence rate ratio [IRR] = 0.16; 95% confidence interval [95% CI], 0.05 to 0.49) and on days when house officers rotated to a new service (IRR = 0.12; 95% CI, 0.02 to 0.91) resulted in fewer reports. The most commonly reported process of care problems were inadequate evaluation of the patient (16.4%), failure to monitor or follow up (12.7%), and failure of the laboratory to perform a test (12.7%). Respondents identified 29 (26. 4%) AEs, 52 (47.3%) PAEs, and 29 (26.4%) other house officer-identified quality problems. An AE occurred in 2.6% of admissions. The hospital incident reporting system detected only one house officer-reported event. Chart review corroborated 72.9% of events. CONCLUSIONS: House officers detect many AEs among inpatients. Confidential peer interviews of front-line providers is a promising method for identifying medical errors and substandard quality. (+info)