Overview of trauma care and its prospect

Trauma is a prominent problem in modern soci-ety,which is called"the disease of developed society"or"the twin brother of modern civilization".Nowada-ys,over one million people die of trauma and severalten million people are injured worldwide each year.InChina,over one hundred thousand people die of trau-ma and several millions are injured each year.There-     

Unplanned admission to the intensive care unit in postoperative patients--an indicator of quality of anaesthetic care?

As a clinical indicator, unplanned admission to the Intensive Care Unit from the operating room has been thought to reflect the quality of anaesthesia care intraoperatively. To explore this concept, we examined all such admissions at three hospitals over a three-month period. Cases were classified according to the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) classification system and an assessment was made as to whether the admission was inevitable or not. Demographic data were collected as well as co-morbidities, severity of illness, length of stay, discharge functional status and destination. There were 165 admissions identified: 55.8% were male, the median age was 63.5 years (range 15-90). There were 24 in-hospital deaths: 151 patients suffered serious morbidity or mortality. In 32 patients (19.4%), the morbidity or mortality was considered at least partially anaesthetic-related, and in 20 (12.1%), under the control of the anaesthetist. There were 28 admissions (17.0%) with a further 9 anaesthetic-related admissions (5.5%) which were considered potentially avoidable. Avoidable anaesthetic-related admissions were due to drug overdosage (5 cases), drug error (1 case), problems relating to preoperative assessment (1 case), aspiration (1 case) and pulmonary oedema (1 case). These findings suggest that unplanned admission to the Intensive Care Unit from the operating room is not a satisfactory indicator of quality of care by the anaesthesia team. This indicator appears to represent mainly the surgical and medical conditions of the patients, and their complications. Only one in twenty unplanned admissions in this series were potentially avoidable due to complications of the anaesthetic or the postoperative analgesia.     

A high court of wound care?

I have just arrived back from two very enjoyable (albeit rainy) days in Galway, attending the Wound Management Association of Ireland's biennial conference. The title of one of the sessions, 'The great debate: technology versus dressings in wound management - is there a difference in outcomes?', caught my eye. Interestingly, while listening to the proceedings, it became apparent that there was more consensus than debate among the delegates, with most agreeing that the key to success is simply the ability to identify which option is most suited to the needs of the patient and wound. Ironically, given that we were talking about new technology, the old phrase 'back to basics' was used repeatedly, referring in this instance to the need for thorough and holistic assessment. Plus ?a change, plus c'est la même chose!     

Patient-centered care of de Quervain’s disease

Purpose

To test the hypothesis that most patients that elect symptomatic treatment of de Quervain’s disease experience symptom resolution.

Materials and methods

Eighty-three of 314 (26%) patients that elected initial symptomatic treatment of de Quervain’s disease responded to a mail survey inquiring about symptom resolution, symptom duration, subsequent opinions and treatments, final impressions and comments.

Results

Seventy-five respondents (90.4%) reported resolution of the pain, including 58 of the 61 (95%) respondents that elected neither corticosteroid injection nor surgery. Among patients with symptom resolution without injection or surgery 48 of 58 (83%) recalled symptoms for fewer than 12 months. The differences in reported average time to symptom resolution were not statistically significant between patients that elected or did not elect a corticosteroid injection.

Conclusions

Considered in the light of important limitations of this data including the reliance on patient recall and the limited response rate to the survey, the data are still intriguing. At least in one surgeon’s practice, most informed patients initially elect symptomatic treatment, and most experience symptom resolution within one year.     

Laparoscopic nephrectomy: new standard of care?

OBJECTIVE: The pace of implementation of a laparoscopic nephrectomy programme is affected by factors including surgical expertise, case load, learning curves and outcome audits. We report our experience in introducing a laparoscopic nephrectomy programme over a 3-year period. METHODS: From January 2001 to December 2003, 187 nephrectomies were performed (105 by conventional surgery, 82 by laparoscopy). Hand-assisted laparoscopy was used predominantly. The indications for surgery, factors affecting the approach and outcome parameters were studied. A cost comparison was made between patients with similar-sized renal tumours undergoing laparoscopic versus open surgery. RESULTS: Most operations were performed for malignancy in both the open (70%) and laparoscopic (67%) surgery groups. The laparoscopic approach was most commonly used in upper tract transitional cell cancers (TCCs; 70% of 30 patients) and benign pathologies (49% of 35 patients), followed by radical nephrectomies (34% of 99 patients) and donor nephrectomies (44% of 23 patients). There was a rapid rise in laparoscopic surgeries, from 30% in 2001 to 58% in 2002. The median hospital stay was 5.8 days in the laparoscopic group and 8.1 days in the open surgery group. The procedure cost for laparoscopic surgery was 4,943 dollars compared with 4,479 dollars for open surgery. However, due to a shorter hospital stay, the total hospital cost was slightly lower in the laparoscopic group (7,500 dollars versus 7,907 dollars). CONCLUSION: The laparoscopic approach for various renal pathologies was quickly established with a rapid increase in the number of laparoscopic procedures.     

Corticosteroids for septic shock--a standard of care?

Septic shock has a crude mortality rate of 45% and claims thelives of 90 000 people each year in the USA alone.¹ An epidemiologicalstudy from France of over 100 000 intensive care unit (ICU)admissions indicates the incidence of septic shock before orfollowing admission to ICU is rising and now affects almost10% of this patient population.² Given the scale and associatedcosts of this problem,^{3 4} it is not surprising that developingsolutions has been a focus of researchers, clinicians, and thepharmaceutical industry. Despite many past disappointments particularlywith antagonists of endogenous mediators,⁵ some recent approacheshave shown promise in prevention or treatment of sepsis     

End of life care in Italian intensive care units: where are we now?

Most patients in the ICU are unable to make decisions for themselves at the end of life (EOL), and the responsibility for these decisions falls to the medical staff and patients' relatives. Therefore, clinicians must frequently communicate with patients' relatives to understand the patients' values and preferences as they perform medical decision making. The family's role in this process varies: the entire burden of decision making could rest with the family, or family members could be informed of the decisions without admission into the decision-making process. In contrast to these two extremes, clinicians and family members may also enter into shared decision making: an exchange of views and opinions between clinicians and the patient's family to enable the two parties to reach decisions together. In this latter scenario, the effectiveness of the discussions that take place between clinicians and family members becomes a crucial marker of high-quality intensive care. In this review, we provide an overview of the current literature concerning the state of EOL care in European and Italian ICUs and then summarize several European and American recommendations for improving EOL care in the ICU. Finally, we examine the opportunity to use shared decision making to improve EOL care in the ICU through interdisciplinary communication, open and realistic discussion of prognosis with families, and an approach respecting different cultural perspectives.     

Does the implementation of a clinical information system decrease the time intensive care nurses spend on documentation of care?

BACKGROUND: The number of intensive care units (ICU) using a clinical information system (CIS) is increasing. It is believed that replacing manual charting with an automatic documentation system allocates nurses more time for patient care. The objective of this study was to measure changes in nurses' working time utilization after the implementation of a CIS in a polyvalent ICU of a large Finnish central hospital. METHODS: An activity analysis-based comparison of the ICU nurses' working time utilization before and after the implementation of a CIS. RESULTS: After the implementation of a CIS the total time the nurses spent on documentation of nursing care increased by 3.6% (NS), 15 min per shift of 8 h per nurse. The total time they spent on patient care increased by 5.5% (P < 0.05), 21 min. Intensive care nursing activities increased by 3.7% (P < 0.05), 14 min. The length of the nurses' ICU experience had some effect on these figures. The demand for nurse labor remained constant. CONCLUSIONS: After the implementation of a CIS, an increase in the time nurses spent on documentation of care was detected, which suggests a need for further development of the system. As all the measured time changes were relatively small, any plans to reduce the ICU staff number with the aid of computers were not justified.     

Use and care of an endotracheal/tracheostomy tube cuff--are intensive care unit staff adequately informed?

BACKGROUND: There is an apparent high incidence of tracheal stenosis in the Bloemfontein area. The aim of this study was to determine intensive care unit (ICU) staff knowledge of the use and care of endotracheal and tracheostomy tube cuffs. METHODS: One hundred and twelve qualified nurses, working in 11 different ICUs, were asked to complete an anonymous questionnaire regarding endotracheal/tracheostomy tube cuffs. RESULTS: The results highlight the following three areas of concern: (i) there was an overall misconception in 38% of the respondents that the function of the cuff was to secure the tube in position in the trachea to prevent self-extubation; (ii) accurate regulation of cuff pressure was not routine practice in any of the ICUs; and (iii) only half of the respondents felt their training regarding cuff care management was sufficient. CONCLUSIONS: ICU staff had misconceptions regarding the function and care of endotracheal/tracheostomy tube cuffs. The concept of a higher cuff pressure for better stabilisation of the tube is probably an important factor that could have caused the increase in tracheal stenosis in the Bloemfontein area. Critical care nursing needs to emphasise the use of current techniques, discourage routine cuff deflation, and encourage collaboration with ICU physicians on standards of care. A protocol that could be used in the ICUs regarding the use and care of an endotracheal/tracheostomy tube cuff is proposed.     

Managing the burden of osteoporosis: is there a standard of care?

Fragility fractures, being a consequence of low bone quality and density, are key clinically relevant markers of bone frailty diseases such as osteoporosis. Numerous barriers to adequate osteoporotic care today have been reported. These include inadequate knowledge and sensitivity to this public health problem. This is compounded by lack of communication and coordination of care. Improvement in the dialogue between orthopaedic surgeons and primary care physicians is a necessary step in the identification and treatment of patients with fragility fractures. Cross-disciplinary educational modules should be produced that include patient-friendly materials.