Liver disease in a district hospital remote from a transplant centre: a study of admissions and deaths.
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The profile of liver disease admissions and associated deaths in a district general hospital was studied to determine whether patients with end stage liver disease are appropriately referred for consideration of liver transplantation. Admission details were provided by the Office of Population Censuses and Surveys (OPCS) and their accuracy was assessed by case note analysis. According to OPCS, 77 patients with liver disease were admitted on 113 occasions between 1 January 1987 and 31 December 1989. The case notes of 74 (96%) were retrieved and examined. Only 64 (86%) had primary liver disease. Twenty four (31%) died of liver failure. Alcohol was the aetiological agent in two thirds. According to accepted criteria, 11 patients were suitable for liver transplant assessment but only three had been referred to a transplant centre. Of the remaining eight, five died during the study period. Two of the three patients referred died without transplantation; one underwent transplant and survived. There is discrepancy between OPCS data and true disease aetiologies, with approximately 40% under reporting of alcoholic liver disease. If this population is representative of the situation nationally, substantial numbers of patients with end stage liver disease might benefit from liver transplantation, but are not referred to a centre. (+info)
Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis.
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BACKGROUND: The benefit of primary percutaneous coronary intervention (PCI) over thrombolysis has been clearly demonstrated in acute myocardial infarction (AMI). However, the best therapeutic strategy for a patient with AMI presenting to acute care services without catheterization facilities remains under debate. Our objective was to gather all available information from clinical trials comparing transfer of patients experiencing AMI for angioplasty versus immediate thrombolysis. METHODS AND RESULTS: We performed a meta-analysis of all data available from published randomized trials and from presentations in scientific sessions of major cardiology congresses comparing the 2 strategies. The primary end point was the combined criteria (CC) of death/reinfarction/stroke as defined in each trial. Relative risk (RR) evaluated the treatment effect. We identified 6 clinical trials including 3750 patients. Transfer time was always <3 hours. The CC was significantly reduced by 42% (95% confidence interval [CI] 29% to 53%, P<0.001) in the group transferred for primary PCI compared with the group receiving on-site thrombolysis. When CC parameters were considered separately, reinfarction was significantly reduced by 68% (95% CI, 34% to 84%; P<0.001) and stroke by 56% (95% CI, -15% to 77%; P=0.015). There was a trend toward reduction in all-cause mortality of 19% (95% CI, -3% to 36%; P=0.08) with transfer for PCI. CONCLUSIONS: Even when transfer to an angioplasty center is necessary, primary PCI remains superior to immediate thrombolysis. Organization of ambulance systems, prehospital management, and adequate PCI capacity appear now to be the key issues in providing reperfusion therapy for AMI. (+info)
Demand and availability of Intensive Care beds. A study based on the data collected at the SUEM 118 Central of Padua from October 1996 to December 2001.
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AIM: This study aims to evaluate the management of intensive care beds according to the demands received by the SUEM 118 of Padua. It has been carried out by examining the reports drawn up by SUEM physicians from October 1996 to December 2001. The study rated the number of patients for whom an admission to the Intensive Care Unit (ICU) was required, according to the specific clinical situation at the moment of the request. A secondary objective was to evaluate if the critically ill patients had been admitted and treated in the most appropriate medical facility. METHODS: The research is based on 7 087 reports concerning a population of adult and pediatric patients for whom an ICU bed was required in the period previously mentioned. For each report, it analyses the following data (keeping them anonymous): date of demand, main pathology and severity of clinical condition, sex and age, provenence and destination. RESULTS: Even though the number of annual demands for an ICU bed made to SUEM Central 118 has remained unchanged (approximately 1 350 per year), the number of beds made available in the operating rooms of the Hospital of Padua markedly increased. What has been experienced so far, and the data collected in this study has revealed, was that the requests for an intensive treatment for the overall population (hospitalized and non hospitalized) increased disproportionally in relation to the availability of ICU beds. In fact, the total number of hospitalizations in the different ICUs rose steadily year by year (from 3 495 in 1996 to 4 640 in 2001). CONCLUSION: The Hospital of Padua is a landmark center for patients who need specialized treatment. It is therefore important to increase the assistance and safety standards of its ICUs. In recent years there has been a great need for specialized ICUs either for more aggressive procedures (neurosurgical, cardiosurgical, respiratory, cardiologic, etc.) or for the increased use of adequate and invasive treatment for advanced diseases. The available resources of ICU beds should be more rationally distributed between the peripheral and the Regional Hospitals, since the activation of an ICU bed in the operating theatre is a valid, transient option. (+info)
Neonatal transfers by advanced neonatal nurse practitioners and paediatric registrars.
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OBJECTIVE: To evaluate the safety and practicality of using advanced neonatal nurse practitioners (ANNPs) to lead acute neonatal transfers. DESIGN: Comparison of transport times, transport interventions, and physiological variables, covering the first four complete years of operating a transport service that uses ANNPs and specialist paediatric registrars (SpRs) interchangeably. SETTING: Tertiary neonatal transport service. PATIENTS: The first 51 transfers of sick infants under 28 days of age by an ANNP led transport team into Nottingham compared with the next consecutive SpR led transfer after each ANNP led one. MAIN OUTCOME MEASURES: Transport times; interventions and support given during stabilisation for transfer and during transfer; condition on completion of transfer, assessed from blood glucose, systolic blood pressure, pH, oxygenation, and temperature. RESULTS: The ANNP led team responded more rapidly to requests for transfer and took longer to stabilise babies. The groups undertook similar numbers of procedures during stabilisation, and there were no differences in the ventilatory and other support that infants needed in transit. The infants transferred by the doctor led group had worse values for pH (doctor led, 7.31 (6.50-7.46); ANNP led, 7.35 (7.04-7.50), p = 0.02) and PaO(2) (doctor led, 6.7 (2.4-13.1); ANNP led, 8.7 (3.5-17.0); p = 0.008) before transfer (all values median (range)). Comparisons of the infant's condition before and after transfer showed a significant improvement in temperature for the infants transferred by ANNP led teams (36.8 degrees C (34.0-37.8) v 37.0 degrees C (34.6-38.0), p = 0.001) and in oxygen saturation (96% (88-100) v 98% (92-100), p = 0.01). There were no differences between the ANNP and doctor led groups in the values obtained for any variable after transfer. CONCLUSIONS: Clinical condition on completion of transport is similar for babies transferred by ANNP and doctor led teams. ANNP led transport appears to be practical and safe. (+info)
Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty: data from the CAPTIM randomized clinical trial.
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BACKGROUND: CAPTIM was a randomized trial comparing prehospital thrombolysis with transfer to an interventional facility (and, if needed, percutaneous intervention) with primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction (STEMI). Because the benefit of thrombolysis is maximal during the first 2 hours after symptom onset, and because prehospital thrombolysis can be implemented earlier than PCI, this analysis studied the relationship between the effect of assigned treatment and the time elapsed from symptom onset. METHODS AND RESULTS: Randomization within 2 hours (n=460) or > or =2 hours (n=374) after symptom onset had no impact on the effect of treatment on the 30-day combined primary end point of death, nonfatal reinfarction, and disabling stroke. However, patients randomized <2 hours after symptom onset had a strong trend toward lower 30-day mortality with prehospital thrombolysis compared with those randomized to primary PCI (2.2% versus 5.7%, P=0.058), whereas mortality was similar in patients randomized > or =2 hours (5.9% versus 3.7%, P=0.47). There was a significant interaction between treatment effect and delay with respect to 30-day mortality (hazard ratio 4.19, 95% CI 1.033 to 17.004, P=0.045). Among patients randomized in the first 2 hours, cardiogenic shock was less frequent with lytic therapy than with primary PCI (1.3% versus 5.3%, P=0.032), whereas rates were similar in patients randomized later. CONCLUSIONS: Time from symptom onset should be considered when one selects reperfusion therapy in STEMI. Prehospital thrombolysis may be preferable to primary PCI for patients treated within the first 2 hours after symptom onset. (+info)
Local health department perspectives on linkages among birthing hospitals.
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OBJECTIVES: To describe perinatal linkages among hospitals, changes in their numbers and their impact on relationships among high-risk providers in local communities. STUDY DESIGN: Data were obtained about the organization of perinatal services in 1996-1999 from a cross-sectional study evaluating fetal and infant mortality review (FIMR) programs nationwide. Geographic areas were sampled based on region, population density, and the presence of a FIMR. A local health department representative was interviewed in 76% (N=193) of eligible communities; 188 provided data about hospitals. RESULTS: Linkages among all hospitals were reported in 143 communities and with a subspecialty hospital in 122. All but 12 communities had a maternity hospital, and changes in the number of hospitals occurred in 49 communities. Decreases in the number of Level II hospitals were related to changes in relationships among providers of high-risk care for mothers and newborns; they were associated with changing relationships only for mothers in Level I hospitals. These relations were noted only where established provider relationships existed. CONCLUSIONS: Decreases in the number of maternity hospitals affect provider relationships in communities, but only where there are established linkages among hospitals. (+info)
Planning for chemical incidents by implementing a Delphi based consensus study.
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This paper provides a practical approach to the difficulties surrounding planning for chemical incidents, based upon the results of a Delphi based consensus study. It is intended to offer advice, which can be implemented at regional and local prehospital and hospital level. The phases of the response that are covered include preparation, management of the incident, delivery of medical support during the incident, and recovery and support after the incident. (+info)
Effects of acuity-adaptable rooms on flow of patients and delivery of care.
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BACKGROUND: Delayed transfers of patients between nursing units and lack of available beds are significant problems that increase costs and decrease quality of care and satisfaction among patients and staff. OBJECTIVE: To test whether use of acuity-adaptable rooms helps solve problems with transfers of patients, satisfaction levels, and medical errors. METHODS: A pre-post method was used to compare the effects of environmental design on various clinical and financial measures. Twelve outcome-based questions were formulated as the basis for inquiry. Two years of baseline data were collected before the unit moved and were compared with 3 years of data collected after the move. RESULTS: Significant improvements in quality and operational cost occurred after the move, including a large reduction in clinician handoffs and transfers; reductions in medication error and patient fall indexes; improvements in predictive indicators of patients' satisfaction; decrease in budgeted nursing hours per patient day and increased available nursing time for direct care without added cost; increase in patient days per bed, with a smaller bed base (number of beds per patient days). Some staff turnover occurred during the first year; turnover stabilized thereafter. CONCLUSIONS: Data in 5 key areas (flow of patients and hospital capacity, patients' dissatisfaction, sentinel events, mean length of stay, and allocation of nursing productivity) appear to be sufficient to test the business case for future investment in partial or complete replication of this model with appropriate populations of patients. (+info)