Increasing clinical,satisfaction, and financial performance through nurse-driven process improvement

Providers and regulatory agencies are increasing their demands for hospitals to document clinical quality and customer satisfaction at a decreased cost. Nurse leaders search for ways to meet these requirements while retaining their most valuable resource: healthcare workers (especially nurses). First-line leadership struggles with balancing quality, cost-effectiveness, and staff retention. The author discusses the planning, methodology, implementation, and outcomes of a staff driven process improvement initiative.     

State substance abuse treatment gaps

This study estimated the adequacy of state substance abuse treatment rates relative to treatment needs. The investigators created composite drug and alcohol treatment need indexes from explicit-mention mortality and substance-defined arrest rates. The indexes were reliable and had evidence of construct validity, but alternative population-at-risk and survey-based need measures did not fair as well. States varied substantially in per capita alcohol and drug treatment needs, although the two did not correlate with each other. While the need indexes correlated significantly with state treatment rates, the adequacy of state treatment rates varied greatly. States with the largest treatment gaps were in the South, Southwest, and northern plains and mountain regions. The failure of the Block Grant formula to reflect the needs of rural states with high-risk minority populations may contribute to disparities in access to services.     

Overview of injection practices in two governorates in Egypt

OBJECTIVE: To describe the extent and characteristics of injection use and injection providers in Egypt, given that unsafe injections are associated with blood-borne pathogen transmission. METHODS: Household surveys of a population-based sample of residents in the Nile Delta and in Upper Egypt; focus group discussions and in-depth interviews with community target groups, formal and informal medical providers. RESULTS: Of 4197 persons interviewed, 26.2% reported receiving an injection in the past 3 months. Of these, 77% reported it was for therapeutic indications. The age-sex specific prevalence of injections was highest among children 0-2 years of age and among older adults. Women were more likely to report having an injection than men, particularly at the age above 20 years. Overall, respondents reported receiving on average 4.2 injections per year, indicating that up to 281 million injections are provided per year in Egypt. Injection administrators were public and private sector physicians, pharmacists, barbers, doctor assistants, housekeepers, relatives and friends. Injection prescribers were mostly private and public sector physicians. Of the 1101 respondents who received an injection in the past 3 months, 92 (8.4%) reported that the provider did not use a syringe taken from a closed sealed packet. CONCLUSION: The frequency of therapeutic injection use is high in Egypt and may contribute to blood-borne pathogen transmission. The Ministry of Health and Population (MOHP) is developing interventions targeted towards promotion of injection safety and reduction of injection overuse on community basis as part of a comprehensive strategy to prevent blood-borne pathogen transmission in Egypt.     

Anopheles species of the mount Cameroon region: biting habits,feeding behaviour and entomological inoculation rates

There is a lack of data on the Anopheles fauna, its biology and the roles played by different vector species in the transmission of malaria in the mount Cameroon region. The biting habits, feeding behaviour and entomological inoculation rates of different Anopheles species during the dry and rainy season were investigated. A total of 2165 Anopheles was collected, 805 in the rainy season and 1360 in the dry season. Five Anopheles species were identified: Anopheles gambiae s.l., An. funestus, An. hancocki, An. moucheti and An. nili. An. gambiae, An. funestus and An. hancocki, recorded during both seasons, were the main vectors of malaria in the region. An. gambiae s.s. was the only member of the An. gambiae (Giles) complex. These three species had their peak activity between 1 and 2 am. A human blood index (HBI) of 98.29% was recorded for fed Anopheles. The sporozoite rate, for all vectors together, was significantly higher in the rainy season (9.4%) than in the dry season (4.2%) with all the species infected by Plasmodium falciparum. The average inoculation rate was 0.44 infective bites per man per night, which adds up to 161 infective bites per year in this study area. Analyses of relative abundance and infection rate of malaria vectors at different sites situated along a transect of 20 km during the dry season showed high heterogeneity in biting and sporozoite rates. No malaria vector was caught at 1200 m a.s.l. The mount Cameroon region should be considered an area of high malaria transmission intensity.     

Coagulation abnormalities in patients with single-ventricle physiology precede the Fontan procedure

OBJECTIVE: Thromboembolic events in patients who have undergone the Fontan operation have been reported to be as high as 20% to 33%. A hypercoagulable state with deficiencies in proteins C and S has been implicated. Using age-matched control subjects, we evaluated whether an altered coagulation state is present earlier in the course of staged single-ventricle repair. METHODS: After informed consent had been obtained, coagulation factors were assayed in 36 infants (mean age, 7.7 +/- 3.6 months) with single-ventricle cardiac defects immediately before undergoing the bidirectional Glenn procedure; 34 infants (mean age, 8.4 +/- 2.6 months) without cardiac disease were assayed as control subjects. Concentration of factors II, V, VII, VIII, IX, and X; antithrombin III; plasminogen; proteins C and S; fibrinogen; serum albumin; and liver enzymes were measured. Normal reference intervals on the basis of the control subjects were determined by using 95% confidence limits. Patient demographic and hemodynamic variables were evaluated as possible predictors of coagulation abnormalities. RESULTS: Concentrations of protein C; factors II, V, VII, IX, and X; plasminogen; fibrinogen; and antithrombin III were significantly lower in the pre-Glenn infants compared with the age-matched control subjects (all P <.001, Student t test). On the basis of multiple logistic regression, no specific hemodynamic variables were predictive of a procoagulant or anticoagulant deficiency. Ventricular dysfunction did predict the presence of multiple coagulation abnormalities (P <.001). CONCLUSION: Procoagulant and anticoagulant factor abnormalities occur early in the course of single-ventricle repair and precede the cavopulmonary connection.     

The fourteen-day rule and colorectal cancer

OBJECTIVE: To examine the effect of the fourteen-day rule on the colorectal service of a district general hospital. METHODS: Prospective audit of all patients referred by general practitioners to the colorectal service of a district general hospital serving a population of approximately 300,000 people. The main outcome measures were: (i) mean interval in days from referral to first clinic appointment; (ii) first clinic appointment to diagnosis; and (iii) overall interval from referral to diagnosis. RESULTS: There was a change in the referral pattern with greater numbers of 'fourteen-day rule' and urgent referrals than expected (P < 0.001). The mean time interval from referral to diagnosis was reduced (P < 0.01). This was due to a reduction in the wait for a first clinic appointment (P < 0.01). The wait between first appointment and diagnosis was unchanged (P < 0.05). Waiting times for patients referred as 'routine' or whose GPs did not specify a priority also improved. CONCLUSIONS: The 'fourteen-day rule' with respect to colorectal cancer has reduced waiting times for a first appointment to see a specialist. Further improvements will require additional resources to reduce the delay for investigations. The effect on long-term survival remains to be seen.     

Current incidence of acute neurologic complications after open-heart operations in children

Background. Previously, neurologic dysfunction was estimated to complicate 25% or less of pediatric open-heart operations. We sought to determine the current incidence and spectrum of early postoperative neurologic complications.

Methods. We undertook a retrospective review of all patients undergoing open heart operations in 1 year at our institution with the goal to identify all neurologic complications occurring in the early postoperative period.

Results. Open-heart operations were performed in 706 children. Sixteen children (2.3%) had neurologic complications develop, including 9 (1.3%) with definite clinical seizures, 1 with suspected seizures and bilateral subdural hemorrhage, 2 with coma after cardiac arrest, 2 with transient mild choreoathetosis, 1 with facial palsy, and 1 with persistent irritability. Causes of seizure were cyclosporin A toxicity posttransplant (4), cerebral ischemia post cardiac arrest (3), and unknown (2). In infants less than 1 year of age, the incidence of seizures was 1.2%.

Conclusions. This review suggests a decrease in acute neurologic morbidity after pediatric open heart operation. Clinical seizures remain the most common complication. Posttransplant, cyclosporin-associated seizures have emerged as an important etiologic category, coincident with an increase in cardiac transplantation in children.     

Fractures of the olecranon: a 15- to 25-year followup of 73 patients

The incidence of olecranon fractures in adults and the long-term outcome of closed olecranon fractures in 45 women and 28 men (mean age, 54 and 36 years at the time of fracture, respectively), were examined at a mean of 19 years after the fracture. The uninjured elbows served as controls. Thirteen percent of the original fractures were displaced less than 2 mm, 65% more than 2 mm, and 22% were multifragmental. Primary treatment consisted of mobilization in 4%, application of a plaster cast in 12%, and open reduction and internal fixation in 84% of the elbows. The incidence of an isolated fracture of the olecranon in individuals older than 16 years was 1.15 per 10,000 person-years. Eighty-four percent of the 73 patients had no complaints at followup, 12% had occasional pain, and 4% had daily pain. Ninety-six percent had an excellent or good outcome. Elbow flexion and extension were reduced but most patients had no or only occasional subjective complaints. Radiographic signs of degenerative changes were found in more than 50% of the formerly fractured elbows, which was more than in the uninjured (11%). Radiographic signs of osteoarthritis were found in 6% of the formerly fractured elbows versus zero percent in the uninjured, of which only two patients had a poor outcome. Isolated, closed fractures of the olecranon in adults have a favorable, long-term outcome.     

Low accuracy and low consistency of fourth-graders' school breakfast and school lunch recalls

OBJECTIVE: To determine the accuracy and consistency of fourth-graders' school breakfast and school lunch recalls obtained during 24-hour recalls and compared with observed intake. DESIGN: Children were interviewed using a multiple-pass protocol at school the morning after being observed eating school breakfast and school lunch. SUBJECTS: 104 children stratified by ethnicity (African-American, white) and gender were randomly selected and interviewed up to 3 times each with 4 to 14 weeks between each interview. STATISTICAL ANALYSIS: Match, omission, and intrusion rates to determine accuracy of reporting items; arithmetic and/or absolute differences to determine accuracy for reporting amounts; total inaccuracy to determine inaccuracy for reporting items and amounts combined; intraclass correlation coefficients (ICC) to determine consistency. RESULTS: Means were 51% for omission rate, 39% for intrusion rate, and 7.1 servings for total inaccuracy. Total inaccuracy decreased significantly from the first to the third recall (P=0.006). The ICC was 0.29 for total inaccuracy and 0.15 for omission rate. For all meal components except bread/grain and beverage, there were more omissions than intrusions. Mean arithmetic and absolute differences per serving in amount reported for matches were -0.08 and 0.24, respectively. Mean amounts per serving of omissions and intrusions were 0.86 and 0.80, respectively. APPLICATIONS/CONCLUSIONS: The low accuracy and low consistency of children's recalls from this study raise concerns regarding the current uses of dietary recalls obtained from children. To improve the accuracy and consistency of children's dietary recalls, validation studies are needed to determine the best way(s) to interview children.