Effectiveness of a prospective physician self-audit transfusion- monitoring system

BACKGROUND: The purpose of this study was to search for a more effective transfusion-monitoring system than the existing system of retrospective peer review. STUDY DESIGN AND METHODS: This research used a study-control, preintervention and postintervention design, to evaluate the effectiveness of a prospective physician self-audit transfusion-monitoring system that functioned without the direct involvement of transfusion service physicians. This research also evaluated the effectiveness of issuing to physicians a memo with transfusion guidelines. Three process indicators were used to assess physician behavior at various stages of the blood-ordering process: 1) the number of crossmatches ordered per admission, 2) the transfusion-to- crossmatch ratio, and 3) the number of blood units returned to the laboratory after physician self-auditing. The study used two outcome indicators to reflect overall blood utilization: 1) the percentage of patients who received red cell transfusions and 2) the number of blood units transfused per recipient each month. RESULTS: The prospective physician self-audit system implemented at the study hospital did not reverse physician transfusion decisions, and the process of issuing to physicians a memo with transfusion guidelines at the control hospital failed to reduce blood usage. However, a transient reduction in blood utilization was observed at the study hospital. CONCLUSION: The reduction was hypothesized to be due to a Hawthorne effect, in which observed behavior is affected by the subject's awareness of the research study.     

Sudden-onset Severe Acute Asthma: Clinical Features and Response to Therapy

Abstract. Objectives : To characterize patients with sudden onset of severe acute asthma (SAA) and to examine whether this presentation is associated with rapid recovery. Methods : Retrospective cohort study of ED visits to a teaching hospital. Subjects were aged 18–64 years, with SAA ( n = 225), denned as initial peak expiratory flow rate (PEFR) ≤40% of predicted. Visits for sudden-onset SAA (≤3 hours of symptoms) were characterized and multivariate logistic regression was used to examine the association between sudden onset and rapid recovery. Results : Patient visits for sudden-onset SAA had different triggers as compared with those for the slower-onset group (p = 0.006). The sudden-onset patients were less likely to report an upper-respiratory-tract infection (17% vs 40%) and more likely to have an unidentifiable trigger (40% vs 19%). In the multivariate logistic regression model, sudden onset was a strong independent predictor of rapid response [odds ratio (OR) 4.3, 95% confidence interval (CI) 1.6–11.6]. Sudden-onset visits were less likely to lead to admission (23% vs 43%, p = 0.03). Conclusions : These data suggest that different triggers may be involved in sudden-onset SAA and that sudden onset of symptoms is independently associated with rapid recovery. In their rapid deterioration and rapid response, these subjects share certain characteristics with "sudden asphyxic asthmatics" and may constitute a population suitable for further study of factors contributing to that condition. While these visits led to admission less frequently, prospective studies are necessary to provide information on duration of response and risk for relapse.     

The extension of 4 degrees C storage time of frozen-thawed red cells

Blood was drawn from volunteer donors and frozen using the high glycerin, mechanical freezing procedure accepted by the United States Navy. Subsequently, the units of blood were thawed and washed. Various anticoagulants were added, and the red cells were stored in a refrigerator at 4 degrees C for periods of up to 28 days. Chemical analyses were performed periodically. These showed that the addition of the anticoagulants ACD, CPD and CPDA-1 caused the red cells to be preserved better than the currently accepted 0.9-percent NaCl, 0.2-percent glucose solution. In vivo 51Cr viability studies performed on blood stored with CPDA-1 for 14 days showed a 24-hour viability of 78.8 +/- 8.4 percent. In a subsequent study, the blood was stored for 21 days prior to freezing and then was rejuvenated and frozen. The cells were thawed, washed, and stored at 4 degrees C with CPDA-1 for an additional 14 days. The 24-hour viability of these cells was determined to be 74.0 +/- 5.1 percent. These findings show that the postthaw storage time of red cells can be increased greatly over the now-accepted 24 hours, if bacterial sterility can be assured.     

The Relationship of Plasma Glucose and HbA1c Levels among Emergency Department Patients with No Prior History of Diabetes Mellitus

Objectives: Patients without a history of diabetes mellitus may be incidentally found to be hyperglycemic in the emergency department (ED). If the hyperglycemia is due to undiagnosed diabetes, then an opportunity for detection exists. Hemoglobin A1c (HbA1c) provides a weighted average of blood glucose levels over the past several months; high HbA1c levels could indicate diabetes. The objective of this study was to determine whether hyperglycemia in ED patients without a history of diabetes was associated with higher HbA1c levels.
Methods: This was a prospective nonconsecutive case series of adults aged 18 years or older presenting to the ED with acute illness for whom a plasma glucose sample was drawn for clinical management. A history of diabetes/hyperglycemia or current symptoms of diabetes excluded patients. HbA1c levels were analyzed for a glucose cutoff of 110 mg/dL; the data were further analyzed using additional glucose cutoffs. Based on the Third National Health and Nutrition Examination Survey outpatient screening data, an HbA1c level ≥6.2% was considered elevated (sensitivity of 63% and specificity of 97% for identifying diabetes).
Results: There were 541 patients enrolled; the glucose level correlated with the HbA1c level ( r = 0.60, p < 0.001). Among the 331 patients with a glucose level ≥110 mg/dL, 22.4% had an elevated HbA1c level; among the 210 patients with a glucose level < 110 mg/dL, 7.6% had an elevated HbA1c level. There were few patients ( n = 13) with a glucose level ≥200 mg/dL, but most (85%) had an elevated HbA1c level. Among the 140 patients with a mildly elevated glucose level (110–125 mg/dL), 16.4% had an elevated HbA1c level.
Conclusions: Elevated HbA1c levels are found in ED patients with elevated random plasma glucose values. ED patients with hyperglycemia may warrant referral for diabetes testing.     

The internal consistency and intra-rater reliability of an assessment practice grid for community nurses

The development of instruments to measure clinical competence in nursing shows little evidence of a systematic approach and studies of reliability and validity are absent. The present study was carried out using data on practice assessment collected in the course of a post-registration nursing programme. The data were analysed for internal consistency and intra-rater reliability. The instrument used to assess practice in the present study is highly internally consistent and there is evidence to support intra-rater reliability. However, further development and testing of the instrument is required.     

HYPERVENTILATION AND DIZZINESS: CASE REPORTS AND MANAGEMENT

SUMMARY Dizziness is a common symptom in patients presenting to an otorhinolaryngologist. Hyperventilation accounts for up to 5% of cases with dizziness and is a contributory factor in a further 20% of cases. Six cases of dizziness due to hyperventilation are presented to illustrate the authors' simple management policy. A high index of suspicion in the absence of an organic cause of dizziness and a simple provocation test will identify these cases. Management is aimed at demonstrating resting hypocapnia, investigations to exclude organic causes of hyperventilation and rehabilitation in collaboration with a clinical psychologist ensures the appropriate treatment for the dizziness and can avoid the development of chronic somatisation behaviours.     

Survey of carer satisfaction with the quality of care delivered to in-patients suffering from dementia

Quality assurance in British National Health Service provision stresses the importance of taking account of the consumer's viewpoint Elderly patients with dementia are not always able to contribute usefully to satisfaction surveys Therefore, their carers' views were sought in order to assess the quality of services offered to this client group Forty-one carers of patients discharged from the eight wards for the elderly mentally ill in Leicestershire, England, were randomly selected Individual focused interviews were conducted in carers' own homes Both quantitative and qualitative data were obtained by use of a questionnaire designed to tap the patients'/carers' experiences from preadmission, through hospital stay to post-discharge Interviewees were asked to describe their favourable/unfavourable impressions of, and reactions to, all aspects of hospital care These interviews were tape-recorded Analysis of the data included quantitative measurements of scale ratings Grounded theory was used to analyse qualitative data A wealth of information was uncovered using this research technique Much that was positive about the service was elicited However, carers highlighted areas where they felt the quality of care could be improved within all the foci discussed Twenty-two recommendations for quality improvements in service provision were made in the report as a result of this survey