Improving asthma documentation in a paediatric emergency department

Objectives: To improve documentation for children presenting to the Emergency Department (ED) of The Children's Hospital with acute asthma.
Methodology: In phase I, the documentation process was analysed using a standard total quality management (TQM) approach to identify specific problems leading to poor documentation. Fifty-two medical records of children presenting over a 3 week period were reviewed for nursing and medical documentation. A set of minimum criteria, consistent with the Paediatric Asthma Management Plan, were established for documentation by both medical and nursing staff. Following dissemination and education, compliance with documentation was evaluated and compared to an asthma survey performed in the ED in 1991. In phase II, a specific proforma for medical assessment was developed and 80 medical records of children presenting over a 3 week period were reviewed. Fifty-two (65%) with completed proformas were evaluated. The outcome measure was the documentation rate for minimum criteria established by TQM process.
Results In phase I, nursing compliance with documentation ranged from 46% for signs of respiratory distress to 83% for a past history of asthma and 100% for pulse rate. Doctors were similarly poor at documenting essential elements such as severity (31%), palpable pulsus paradoxus (29%), the child's usual doctor (46%) and follow-up arrangements (21–56%). In phase II, the documentation of the severity of acute asthma (42%) and of the child's usual doctor (42%) remained poor but there were statistically significant improvements in documentation of interval medications, palpable pulsus paradoxus, respiratory rate, pre-treatment oximetry, education, follow-up arrangements and communication letters.
Conclusion The process of TQM has proved valuable in improving some aspects of documentation of children presenting to ED with acute asthma. It remains to be shown whether improved documentation will result in improved outcome.     

RESPIRATORY SYMPTOMS IN TASMANIAN ADOLESCENTS: A FOLLOW UP OF THE 1961 BIRTH COHORT

The 1961 birth cohort of Tasmanians ( n = 8410) was initially surveyed in 1968 and was followed up in 1974 for the history and presence of respiratory symptoms and signs. The study was designed to describe and compare the natural histories of wheeze and productive cough. In 1981 a 10% stratified random sample of the original cohort was again followed up and this sample's responses were compared across the three surveys. Wheezing was found to be more persistent than productive cough. Wheezers were twice as likely as coughers to persist with their symptoms to the age of 20. These persistent wheezers represented 3.6% of the cohort available for follow-up in 1974 ( n = 7132). Wheezing was also invariably associated with decreased spirometric performance, particularly FEV at 0.5 s and FEF 25–75. The new wheezers first detected in 1974 had had significantly decreased spirometry measurements in 1968 compared to those of their coughing or symptom-free peers. An early history of cough was associated with triple the incidence of wheeze in previously asymptomatic children. Hayfever and eczema were associated with persistence of wheeze. A child with either of these diagnoses was four times as likely to persist in wheezing to the age of twenty than a wheezer without atopic complaint. No significant associations could be demonstrated between wheezing and smoking.     

Antenatal fetal blood sampling for the management of alloimmunized pregnancies: effect upon maternal anti-D potency levels

Summary. Increase in maternal anti-D concentrations after intrauterine investigation has been studied retrospectively in 95 rhesus (D) alloimmunized pregnancies; 48 were managed by fetal blood sampling (FBS) procedures (using fetoscopy or ultrasound-guided needle sampling) and 47 using amniocentesis. In those pregnancies where the fetus was rhesus (D) positive, the frequency of procedure-related increases (>50%) in maternal anti-D potency was estimated following single procedures and found to be similar for the two methods of FBS employed (28%) and for amniocentesis (31%). The proportion of pregnancies showing an increase in anti-D potency was higher after ultrasound-guided needle sampling (75%) than after fetoscopic FBS (40%) and after amniocen tesis (44%).     

Fetal umbilical artery flow velocity waveforms and placental resistance: pathological correlation

Summary. Placental microvascular anatomy was correlated with antenatal assessment of the umbilical circulation in 106 patients to further validate the measurement of the A/B ratio (the ratio of peak systolic to least diastolic flow velocity) of the umbilical artery flow velocity time wave-forms as an index of blood flow resistance. Three groups of patients were studied: a normal group of 38 uncomplicated pregnancies, a control group of 33 potentially 'at risk' pregnancies with a normal A/B ratio matched by risk factors and gestation with the third group of 35 pregnancies with a high A/B ratio. Placental arterial resistance was quantitated by counting the number of small muscular arteries (<90 μm diameter) in the tertiary stem villi in a standard microscopic field (mean 18·5 fields/placenta). The modal small arterial vessel count was shown to be significantly less in the group with a high fetal risk and a high A/B ratio (1–2 arteries/field) than in both the normal and control groups (7–8 arteries/field). The tertiary villus count did not vary between groups. Antenatal studies of umbilical artery flow velocity waveforms with Doppler ultrasound identify a specific microvascular lesion in the placenta characterized by obliteration of small muscular arteries in the tertiary stem villi.     

Fetal umbilical artery flow velocity-time waveforms in twin pregnancies

Summary. The umbilical artery flow velocity-time waveforms were studied in 76 twin pregnancies. The ratio of peak systolic (A) to least diastolic (El) velocity was calculated for each fetus as an index of umbilical placental flow resistance. Seventy-one sets of twins were studied within 14 days before delivery. In 65 cases both twins were alive at the time of study. In 32 pregnancies both fetuses were of birthweight appropriate for gestational age (AGA) and had A/B ratios within the normal singleton range. In 33 pregnancies one or both of the liveborn infants were small for gestational age (SGA) and in 78% of these at least one fetus had an elevated A/B ratio. Discordancy in birthweight and A/B ratio was associated with growth retardation. Clinically manifest twin-to-twin transfusions occurred in five of the ten pregnancies resulting in an SGA infant (eight with discordant weight) associated with a normal and concordant A/B ratio. Two twin-to-twin transfusions were associated with perinatal death. The placentas were examined in 61 patients. In 43 dichorionic pairs the A/B ratio was elevated in 12 of the 18 where there was at least one SGA infant. There was a greater incidence of growth retardation in the monochorionic pairs (12 of 18). Only seven of these were identified by an elevated A/B ratio. In 10 of these 18 pairs vascular anastomoses were demonstrated on placental inspection and in a further two there was evidence of twin-to-twin transfusion by haemoglobin discrepancy. Twin pregnancy may result in the birth of a small-for-dates infant because of intrauterine growth retardation or twin-to-twin transfusion. An abnormally elevated A/B ratio identifies growth retardation. In twin-to-twin transfusion the A/B ratio of the two fetuses is similar (crossed circulation) yet difference in size may be seen on ultrasound measurement.     

The effects of lithium on vascular development in the chick area vasculosa

The effects of lithium on vascular development were examined using the chick embryo area vasculosa in shell-less culture as an experimental model. Embryos were explanted after 48 h in ovo and LiCl (50, 100, 150 and 200 μg in 10 μl water) was applied to the centre of the blastodisc. Controls were untreated or given equimolar amounts of NaCl. At 24 h and 48 h after treatment, untreated and NaCl controls were identical, having well developed extraembryonic vessels. At doses of 100 μg and greater, LiCl significantly inhibited normal vascular development and expansion of the area vasculosa in the majority of explants. In many specimens blood islands continued to form but their assembly into primitive vessels was prevented, indicating that lithium affects the mechanism regulating the assembly of vascular endothelium. At the same time the embryos were alive but retarded in development compared with controls. When LiCl (150 μg) was applied to cultures explanted after 72 h in ovo (when the primary vascular network had already formed through vasculogenesis) no adverse effects were seen. This suggests that lithium affects vasculogenesis but not angiogenesis. Treatment with myo-inositol completely reversed the effects of lithium in a time dependent manner indicating that the phosphatidylinositol second messenger cycle may be involved in the cellular events of vasculogenesis. Finally the results of this study show that the yolk sac vasculature is particularly vulnerable to lithium and the consequent effects of this interference on embryonic development are discussed.