Quality improvement strategies for organizational change: a multiphase observational study to increase insight into nonparticipating organizations

Background

The scope of implementation research is often restricted to the analysis of organizations that participate voluntarily in implementation interventions. The recruitment of participants for a quality improvement collaborative increases awareness of the specific innovation. The objective of this multiphase observational study was to identify differences between organizations that participated in a large-scale implementation project aiming to improve perioperative care, functional recovery, and length of hospital stay after gynecologic surgery and organizations that did not participate. A secondary objective was to explore how perioperative practice changed among nonparticipants.

Methods

Of the seven gynecology departments of nonparticipating Dutch hospitals, five agreed to participate in a retrospective analysis. Baseline data of participating hospitals’ (N?=?19) characteristics, time to functional recovery, and length of hospital stay were compared. Outcome measures for the subsequent pre-post awareness study in the five nonparticipating hospitals were: (1) overall adherence to predefined evidence-based perioperative elements; and (2) change in functional recovery and length of hospital stay. Multivariable regression models, adjusted for baseline characteristics, were used for analysis.

Results

In retrospect, nonparticipating and participating hospitals did not differ in baseline characteristics, functional recovery, and length of hospital stay. In three of the five nonparticipating hospitals, adherence to the selected evidence-based perioperative elements increased significantly after awareness of the trial (overall mean difference 9.7%, 95% CI 6.9 to 12.5%, p?<? 0.001). Linear regression models revealed no statistically significant or clinically relevant differences in time to functional recovery (mean difference???0.2?days, 95% CI -0.7 to 0.2, p?=?0.319) or length of hospital stay (mean difference???0.4?days, 95% CI -1.3 to 0.5, p?=?0.419) in the nonparticipating hospitals. None of these hospitals managed to reduce time to functional recovery or length of hospital stay significantly.

Conclusions

No differences in perioperative outcomes between the nonparticipating and participating hospitals were identified at baseline. Despite the statistically significant improvement in overall evidence-based perioperative care, the awareness raised by recruitment activities alone was not enough to reduce time to functional recovery and length of hospital stay in nonparticipating hospitals. Insight into the trends of nonparticipants is valuable to existing implementation effectiveness research.

     

Hematological Diagnostic Markers of Acute Appendicitis in Children

Background

White blood cell (WBC) and platelet indices are useful biomarkers in many inflammatory diseases. A study was made of possible WBC and platelet indices in children with acute appendicitis.

Methods

We reviewed the results of the complete blood count tests made on admission of 150 children with acute appendicitis (94 boys, 56 girls) and those of 74 healthy children (46 boys, 28 girls). We compared the WBC and platelet indices between the children with acute appendicitis and healthy children and between the complicated and uncomplicated cases of appendicitis.

Results

The children with acute appendicitis had higher WBC, neutrophil count, neutrophil percentage and neutrophil/ lymphocyte ratio and lower lymphocyte count and lymphocyte percentage than the healthy children. Cases of appendicitis with complications had lower lymphocyte count, lymphocyte percentage and higher neutrophil to lymphocyte ratio than those without complications. In girls WBC, neutrophil count and neutrophil percentage were higher in complicated acute appendicitis. WBC, neutrophil count, neutrophil percentage, lymphocyte percentage and a neutrophil/lymphocyte ratio >2.5 were accurate markers for acute appendicitis in children, but not for detecting complicated cases. Girls with acute appendicitis had lower platelet distribution width than healthy girls, with high sensitivity and positive predictive value at platelet distribution width <12.4%, but moderate specificity and negative predictive value.

Conclusions

The Neutrophil/lymphocyte ratio can be used as an additional diagnostic marker of acute appendicitis in children, but cannot detect complications, and platelet distribution width can be an additional marker for confirming, but not excluding, acute appendicitis in girls.

     

Treatment of distal radius fractures with locking plates: an update

Internal fixation with volar locking plates has revolutionized the treatment of distal radius fractures. Manufacturers have introduced plate designs that closely follow the anatomy of the distal radius. However, use of volar plates has also led to the emergence of new types of complications. While the use of monoaxial or polyaxial locking screws and of minimally invasive techniques (arthroscopy, preservation of pronator quadratus) increases the cost of the surgical procedure, it results in a tangible benefit for patients, allowing them to move their wrist almost immediately after surgery and to quickly regain their autonomy. We reviewed the literature to analyze the level of proof.     

Treatment of dialysis catheter-related Enterococcus bacteremia with an antibiotic lock: a quality improvement report

BACKGROUND: Catheter-related bacteremia (CRB) is a frequent complication of tunneled dialysis catheters, and Enterococcus is a common infecting organism. CRB may be treated by instilling an antibiotic lock into the catheter lumen in conjunction with systemic antibiotics. The efficacy of this approach in Enterococcus bacteremia is unknown. DESIGN: Quality improvement report. SETTING & PARTICIPANTS: 64 catheter-dependent hemodialysis outpatients with vancomycin-sensitive Enterococcus bacteremia treated with a uniform antibiotic lock protocol. Clinical outcomes were tracked prospectively. QUALITY IMPROVEMENT PLANS: Patients received intravenous vancomycin for 3 weeks in conjunction with a vancomycin lock instilled into both catheter lumens after each dialysis session. MEASURES: Treatment failure was defined as persistent fever 48 hours after initiation of antibiotic therapy or recurrent Enterococcus bacteremia within 90 days. A clinical cure was defined as fever resolution without recurrent bacteremia. Major infection-related complications within 6 months were documented. RESULTS: Treatment failure occurred in 25 patients (39%) because of persistent fever in 10 and recurrent bacteremia in 15. Treatment success occurred in 39 patients (61%). A serious complication of Enterococcus CRB occurred in 4 of 64 patients (6%); endocarditis in 1 and osteomyelitis in 3. The frequency of serious complications was 16% (4 of 25 patients) in those with treatment failure compared with 0% (0 of 39 patients) in those with treatment success (P = 0.01). LIMITATIONS: This was a single-center study. We did not measure serum vancomycin. CONCLUSIONS: An antibiotic lock protocol permits catheter salvage in 61% of hemodialysis patients with Enterococcus CRB. Serious complications occur in 6% of patients and are more common in those with treatment failure.     

Laparoscopic Appendicectomy: Calculating the Cost

INTRODUCTION

Laparoscopic appendicectomy is a commonly performed procedure presenting a considerable cost burden. Given the additional operative costs of laparoscopic versus open appendicectomy, it is not clear whether the national tariffs are appropriate for laparoscopic appendicectomy. We conducted a study to establish the institutional costs, and to determine whether re-imbursement according to the national tariffs was sufficient.

PATIENTS AND METHODS

Data were collected prospectively on patients undergoing laparoscopic appendicectomy within Leeds Teaching Hospitals Trust. Theatre and bed costs were obtained. Cost analysis was performed, and costs were compared to the re-imbursement due.

RESULTS

Fifty laparoscopic appendicectomies were performed. Median operative time was 60 min. The median total operative cost of laparoscopic appendicectomy was £906. Median equipment cost for laparoscopically completed cases was £254. Median total in-patient cost was £1617 (range, £880–£3360). This compared with a mean re-imbursement of £1981 representing a cost benefit of £233 per case (P = 0.0009).

CONCLUSIONS

Despite a liberal use of disposable equipment, laparoscopic appendicectomy can still be performed within the confines of the national tariffs. There is a considerable variation in the cost of this procedure, and it may be possible to reduce costs by more stringent use of disposable equipment and standardising recovery protocols.     

Biologics in oral medicine: Sjogren syndrome

Oral Diseases (2012) doi:10.1111/j.1601‐0825.2012.01932.x Biologic therapy has a potential to benefit patients with orofacial manifestations of Sjogren syndrome (SS). The most appropriate use of biologics would appear to be in patients with severe or multisystem features of SS, but their use early in the pathogenesis has the potential to prevent disease progression. Tumour necrosis factor‐alpha blockade has not proven effective in SS. B‐cell depletion using rituximab has been of benefit, mainly in relation to extraglandular features, and to some extent in relation to hyposalivation where there is still residual salivary function. Rituximab is also effective in the treatment of SS‐associated (extrasalivary) lymphomas, although the therapeutic response in salivary lymphoma is poorer. Rituximab is given as a single or periodic intravenous infusion. Potential adverse effects exist, notably infusion reactions and infection, and so a full risk/benefit analysis is indicated for prospective patients. This and clinical use is best performed and monitored in conjunction with rheumatologists with appropriate training and experience in biologic therapies. Further studies of rituximab in SS are ongoing, and newer agents under trial include belimumab.     

Myeloid-associated differentiation antigens on stem cells and their progeny identified by monoclonal antibodies

Within the hematopoietic system, monoclonal antibodies reactive with antigenic determinants, expressed in a lineage- and stage-restricted fashion, can be used to map myeloid differentiation. We have generated a series of monoclonal antibodies that reacts with myeloid-associated determinants on committed myeloid stem cells and their progeny. Their reactivity with peripheral blood cells was identified by immunofluorescence assays, with bone marrow cells by fluorescence- activated cell sorting, and with committed hematopoietic progenitor cells by both cytotoxic assays and fluorescence-activated cell sorting. Antibody 1G10, which has previously been reported to react with cells of the granulocytic lineage and with a minor subset of mature monocytes, was shown to react with granulocyte-macrophage colony- forming units (CFU-GM). Three antibodies not previously characterized (T5A7, L4F3, L1B2) were shown to react with both granulocytic and monocytic cells and in fluorescence-activated cell sorting studies to detectably stain granulocytic cells at different stages of maturation. These three antibodies also react with CFU-GM, two (L4F3 and L1B2) reacting with all CFU-GM, while T5A7 reacts with only a portion of the day 7 CFU-GM. Antibody L4F3 also reacts with a portion of erythroid burst-forming units (BFU-E). In contrast, the previously reported antibody 5F1, which reacts with monocytic cells, nucleated erythroid cells, and platelets, was shown to react with erythroid colony-forming units (CFU-E). Potential applications of these antibodies to studies of normal and malignant hematopoiesis are discussed.