ABC–VED analysis of expendable medical stores at?a tertiary care hospital

Background

The modern system of medicine has evolved into a complex, sophisticated and expensive treatment modality in terms of cost of medicines and consumables. In any hospital, approximately 33% of total annual budget is spent on buying materials and supplies including medicines. ABC (Always, Better Control)–VED (Vital, Essential, Desirable) analysis of medical stores of a large teaching, tertiary care hospital of the Armed Forces was carried out to identify the categories of drugs needing focused managerial control.

Methods

Annual consumption and expenditure data of expendable medical stores for one year was extracted from the drug expense book, followed by classification on its annual usage value. Subsequently, the factor of criticality was applied to arrive at a decision matrix for understanding the need for selective managerial control.

Results

The study revealed that out of 1536 items considered for the study, 6.77% (104), 19.27% (296) and 73.95% (1136) items were found to be A, B and C category items respectively. VED analysis revealed that vital items (V) accounted for 13.14% (201), essential items (E) for 56.37% (866) and desirable accounted for 30.49% items (469). ABC–VED matrix analysis of the inventory reveals that only 322 (21%) items out of an inventory of 1536 drugs belonging to category I will require maximum attention.

Conclusion

Scientific inventory management tools need to be applied routinely for efficient management of medical stores, as it contributes to judicious use of limited resources and resultant improvement in patient care.     

Delayed inpatient diagnosis and isolation of active pulmonary tuberculosis patients,a large tertiary care academic hospital experience in Riyadh,Saudi Arabia: What are we missing?

Objectives:To identify pulmonary tuberculosis (PTB) delayed inpatient diagnosis duration and contributing factors in an academic center in Saudi Arabia (SA).Methods:Retrospective review of all culture-confirmed PTB cases between May 2015 and April 2019. The outcomes were the timing between admission and suspicion of PTB or isolation to either early group (within 24 hours of admission) and late group (24 hours after admission).Results:Forty-nine cases were included with a median age of 49 years; a third of them were above 65 years of age. Most patients were of Saudi nationality and male. Approximately 38% of the cases were in the delayed group, half of them were smear-positive, with an average delay of 5.5 days. This was significant with age above 65 years (odds ratio [OR]=8.93, 95% confidence interval [CI]=2.22-35.95) presence of non-respiratory symptoms (OR=5.6, 95% CI=1.56-19.98), malignancy (OR=13.38, 95% CI=1.46-122.71), chronic medical problems (OR=4.90, 95% CI=1.31-18.32), missed chest x-ray findings (OR= 48, 95% CI=8.63-266.88) or procalcitonin level above 0.5 ng/mL (OR=12, 95% CI=1.58-91.08).Conclusion:Physicians in SA need to have a low threshold for PTB consideration in elderly patients or those with a history of malignancy. A careful review of the initial chest x-ray might help to overcome missing cases of PTB.     

Paediatric palliative care at home: a single centre’s experience

INTRODUCTION

There is increased awareness of paediatric palliative care in Malaysia, but no local published data on home care services. We aimed to describe the paediatric experience at Hospis Malaysia, a community-based palliative care provider in Malaysia.

METHODS

We conducted a retrospective case note review of patients aged up to 21 years who were referred to Hospis Malaysia from 2009 to 2013.

RESULTS

A total of 137 patients (92 male, 45 female) with a median age of 140 (3–250) months were included in this study. The majority (71.5%) had malignancies. At referral, 62 patients were still in hospital and 17 died prior to discharge. A total of 108 patients received home visits. At the first home visit, 89.8% of patients had at least one physical symptom. Pain was the most common (52.5%) symptom. Patients had various supportive devices: 39 were on feeding tubes, ten had tracheostomies, five were on bilevel positive airway pressure and ten had urinary catheters. 66 families discussed the preferred location of care at end-of-life. Among those who died, 78.9% died at home, as they preferred (p < 0.001). Regression analysis showed no statistically significant association between a home death and age, diagnosis and number of home visits. Bereavement follow-up occurred for 93.3% of families.

CONCLUSION

Community care referrals tend to occur late, with 25.5% of patients dying within two weeks of referral. At referral, patients often had untreated physical symptoms. The majority of families preferred and had a home death.     

Autopsy study of febrile deaths during monsoon at a tertiary care institute in India: Is malaria still a challenge?

Background:

To utilise an autopsy-based approach to study the febrile deaths and deaths due to malaria during monsoon period of three years at a tertiary care teaching hospital in Mumbai, India.

Materials and Methods:

All autopsies done at the hospital during monsoon period from 2005 to 2007 when fever was the main presenting symptom were included in the study. Monsoon period was defined from June to September. A study on the duration of hospital stay of malaria deaths was also attempted.

Results:

There were 202 autopsies of febrile illness during the study period. Malaria resulted in 20.8% of the deaths besides other causes. A majority of deaths had intrapulmonary haemorrhages as the only pathological finding. Incidence of malaria deaths was more during monsoon period than the non-monsoon period. Plasmodium falciparum was the most common species responsible for malaria deaths while cerebral malaria was the most common mode of death. In 27% of the cases, post-mortem examination helped to arrive at the correct final diagnosis. In 88.1% of the cases, malaria deaths occurred within the first 24 hours of admission to the hospital.

Conclusion:

The study reiterates the fact that malaria remains a preventable but major cause of death in India, predominantly during the monsoon period. The study also emphasises the importance of developing treatment protocols for malaria during such crucial times besides reinforcing the existing preventive measures.     

Clinical neurophysiology referral patterns to a tertiary hospital — a prospective audit

Background Cork University Hospital (CUH) provides a tertiary service for all neurophysiology referrals in the Southern Health Board region. Aim To ascertain the number, source, symptoms and diagnosis of neurophysiology referrals at CUH. Methods We did a prospective audit of the referral patterns to the neurophysiology department over a 12-week period. Results Of 635 referrals, 254 had electromyograms (EMG), 359 had electro-encephalograms (EEG), 18 had visual evoked potentials (VEP), three had somato-sensory evoked potentials (SSEP) and one had multiple sleep latency tests (MSLT). We analysed the demographic pattern, reason for referrals, the average waiting time for neurophysiology tests and the patterns of diagnosis in this audit. Conclusions Patients from County Cork are making more use of the neurophysiology services than patients from other counties within the Southern Health Board. The average waiting time for an EEG was 32 days and for an EMG was 74 days. However, more than 35% of those patients waiting for an EEG or an EMG had their tests done within four weeks of referral. The appointments of EEG and EMG were assigned on the basis of clinical need.     

Do we need a national electronic summary care record?

Electronic referrals and discharge summaries can improve the quality and timeliness of clinical communication. The electronic summary care record (SCR) extends the concept of digital health summaries to create a perpetually updated and centrally stored summary of care, extracting key data from local systems after each encounter. The only major SCR evaluation to date, in England, found that rates of usage were low, and any impact on care was difficult to quantify. The SCR is seen by some as a first step to building a national distributed shared electronic health record (SEHR). However, the SCR may be a problematic diversion, creating a need for centralised databases, while the SEHR can function by sharing locally stored records, letters and discharge summaries. Uncertainty about the quality and provenance of SCR data raises concerns about patient safety, as key data may be absent and old data may persist, partly because of a lack of ownership of the summary. A national e-health strategy should emphasise the true stepping stones to a distributed and shared electronic record, including encouraging the uptake and meaningful use of electronic clinical records, clinical messaging, electronic discharge summaries and letters, and services such as decision support and e-prescribing, all of which have good evidence to support them.     

Can we do better in end-of-life care? The mixed management model and palliative care.

The increasing duration of life from disease diagnosis to death in cancer and chronic non-malignant illnesses argues for a revised approach to end-of-life care that incorporates the principles of palliative care from an earlier stage (ie, a stage at which curative and/or life-prolonging treatments are still being provided). The provision of active treatment and comfort measures/death preparation in parallel has been called the "mixed management model" of end-of life care.     

Profile of hypopituitarism in a tertiary care hospital of eastern India--is quality of life different in patients with growth hormone deficiency?

Hypopituitarism is of diverse aetiology. Apart from pituitary adenoma and Sheehan's syndrome, snakebite is a common aetiology of hypopituitarism. A total of 82 patients of hypopituitarism were studied. Biochemical and radiological investigations were done in all the cases. A quality of life questionnaire was put among the patients. Scores were calculated from the answers of the questionnaire and they were assessed about quality of life. Though growth hormone deficiency is associated with poor quality of life there were no significant differences with patients with hypopituitarism without any growth hormone deficiency.     

Can health care teams improve primary care practice?

In health care settings, individuals from different disciplines come together to care for patients. Although these groups of health care personnel are generally called teams, they need to earn true team status by demonstrating teamwork. Developing health care teams requires attention to 2 central questions: who is on the team and how do team members work together? This article chiefly focuses on the second question. Cohesive health care teams have 5 key characteristics: clear goals with measurable outcomes, clinical and administrative systems, division of labor, training of all team members, and effective communication. Two organizations are described that demonstrate these components: a private primary care practice in Bangor, Me, and Kaiser Permanente's Georgia region primary care sites. Research on patient care teams suggests that teams with greater cohesiveness are associated with better clinical outcome measures and higher patient satisfaction. In addition, medical settings in which physicians and nonphysician professionals work together as teams can demonstrate improved patient outcomes. A number of barriers to team formation exist, chiefly related to the challenges of human relationships and personalities. Taking small steps toward team development may improve the work environment in primary care practices.     

Are district general hospital patients with unstable angina at a disadvantage?

Objective: To determine whether patients with non-ST elevation acute coronary syndromes requiring coronary angiography and revascularisation have inferior access to these services if admitted to district general hospitals (DGHs) compared with similar patients admitted to a base hospital containing a tertiary cardiac centre. Design: Prospective, consecutive monitoring of all patients with acute coronary syndromes accepted by the tertiary cardiac centre for angiography and revascularisation over a three month period (1 April to 30 June 2002). Participants: All patients accepted for angiography from DGHs and from within the base hospital with a diagnosis of acute coronary syndromes. Setting: Tertiary cardiac facility (Manchester Heart Centre at Manchester Royal Infirmary (MRI)). Main outcome measure: Time waited from referral to angiography and revascularisation. Results: A total of 184 patients with a diagnosis of non-ST elevation acute coronary syndromes underwent angiography with a view to revascularisation. Of these, 89 (48%) were admitted initially to MRI and 95 (52%) were admitted to a feeder DGH. DGH patients waited significantly longer from admission to angiography than MRI patients (median 13 days (25th-75th percentiles 7–19) v 5 days (3–8) respectively; p<0.0005). DGH patients therefore also waited longer from admission to revascularisation (15 days (6–20) v 6 days (3–9) respectively). Once transferred into the Manchester Heart Centre, DGH patients underwent angiography within a median of 1 day (1–2). More DGH patients than those from MRI underwent both coronary artery bypass grafting (21 (22%) v 8 (9%) respectively; p=0.015) and percutaneous coronary intervention (44 (46%) v 32 (36%) respectively; p=NS). Conclusion: Patients admitted to feeder DGHs with non-ST elevation acute coronary syndromes wait significantly longer for access to invasive coronary assessment and revascularisation than similar patients admitted in the hospital that incorporates the tertiary cardiac centre. This inequity of access is determined by postcode rather than clinical priority.     

Can we learn from eugenics?

Eugenics casts a long shadow over contemporary genetics. Any measure, whether in clinical genetics or biotechnology, which is suspected of eugenic intent is likely to be opposed on that ground. Yet there is little consensus on what this word signifies, and often only a remote connection to the very complex set of social movements which took that name. After a brief historical summary of eugenics, this essay attempts to locate any wrongs inherent in eugenic doctrines. Four candidates are examined and rejected. The moral challenge posed by eugenics for genetics in our own time, I argue, is to achieve social justice.     

Can accurate immunization rates be determined in a primary care clinic?

Based on the data that we collected in our clinic, we were unable to determine the immunization rates of our patients accurately. Despite multiple telephone calls to families and health departments and an exhaustive chart review, 87 of the 261 families studied could not be contacted, thereby making an analysis of immunization data impossible. Another technique of tracking immunizations, such as a statewide or national registry, is needed to obtain accurate immunization data.     

Dying in a West Virginia acute care hospital: what is it like?

To gain insight into the demographics and experiences of dying patients in a West Virginia acute care hospital, a chart review was conducted of all patients dying over a four-week period in 1997. Most of these patients were usually older with chronic progressive diseases. Half the patients underwent life-sustaining treatment in the last three days of life, and most patients had multiple nonpalliative interventions during this period. Interventions were refused or requested to be stopped by patients or families in over one third of the cases. A poor expected outcome was documented for more than two-thirds of the group. Do-Not-Resuscitate orders were written for most patients often within three days of death. Pain assessment was poorly documented. These findings are consistent with other studies of the hospitalized dying. Reasons for the continuation of non-palliative measures in the terminally ill are explored. Incorporation of palliative care programs into the hospital setting is recommended as a means to improve end-of-life care.     

What do patients value in their hospital care? An empirical perspective on autonomy centred bioethics

OBJECTIVE: Contemporary ethical accounts of the patient-provider relationship emphasise respect for patient autonomy and shared decision making. We sought to examine the relative influence of involvement in decisions, confidence and trust in providers, and treatment with respect and dignity on patients' evaluations of their hospital care. DESIGN: Cross-sectional survey. SETTING: Fifty one hospitals in Massachusetts. PARTICIPANTS: Stratified random sample of adults (N=27 414) discharged from a medical, surgical, or maternity hospitalisation between January and March, 1998. Twelve thousand six hundred and eighty survey recipients responded. MAIN OUTCOME MEASURE: Respondent would definitely be willing to recommend the hospital to family and friends. RESULTS: In a logistic regression analysis, treatment with respect and dignity (odds ratio (OR) 3.4, 99% confidence interval (CI) 2.8 to 4.2) and confidence and trust in providers (OR 2.5, CI 2.1 to 3.0) were more strongly associated with willingness to recommend than having enough involvement in decisions (OR 1.4, CI 1.1 to 1.6). Courtesy and availability of staff (OR 2.5, CI 2.1 to 3.1), continuity and transition (OR 1.9, CI 1.5 to 2.2), attention to physical comfort (OR 1.8, CI 1.5 to 2.2), and coordination of care (OR 1.5, CI 1.3 to 1.8) were also significantly associated with willingness to recommend. CONCLUSIONS: Confidence and trust in providers and treatment with respect and dignity are more closely associated with patients' overall evaluations of their hospitals than adequate involvement in decisions. These findings challenge a narrow emphasis on patient autonomy and shared decision making, while arguing for increased attention to trust and respect in ethical models of health care.