Air transport of the sick newborn infant: audit from a sparsely populated county in Norway

The aim of this study was to describe principal problems and to analyse transport times, stabilizing procedures, adverse events during transfer, outcome, effectiveness and the care of infants transferred by air from district general hospitals and maternity homes to a central hospital. Transfer times, equipment adverse events and clinical deterioration were recorded as they occurred. Data regarding clinical problems, diagnoses and outcome were collected retrospectively from hospital records. During the study period (1984-95) 275 infants (267 transports) were transferred by fixed-wing aircraft (233) or helicopter (34). Median time from request of transfer to arrival of the transport team (usually a neonatal nurse and a paediatrician) was 120 min, median stabilizing time 60 min. Ninety-six infants (35%) were intubated, 62 (22.5%) by the transport team. During 34 transports (12.7%), equipment-related adverse events occurred making six infants worse. Ten more infants deteriorated during transit. A significant correlation between birthweight and after-transfer temperature was recorded. After-transfer temperature for very low birthweight (<1500 g, VLBW) infants was significantly higher when the transport team attended the delivery than when they did not (35.9 degrees C vs 34.7 degrees C). All nine infants (3.2%) with after-transfer temperature <34.0 degrees C died, 15 infants (5.5%) died within 24 h after transfer and 20 (7.3%) died later. Adjusted OR for death among transported versus in utero transferred VLBW infants was 3.8 (1.4-10.4). Every effort should be taken to transfer VLBW infants in utero. If preterm deliveries at 26-28 weeks of gestation at district general hospitals is unavoidable, an early request for the neonatal transport team to be there at delivery is advisable. Transport of very immature infants <26 weeks gestational age is not recommended. An outreach educational program ("Team Pink Newborn") has been created. Staff training to combat hypothermia and regular inspection and control of the transport equipment by three neonatal intensive care nurses has now been implemented.     

Dutch case-control study of anaesthesia-related morbidity and mortalityRationale and methods

To date, anaesthesia-related mortality, morbidity and risk factors have almost exclusively been studied qualitatively rather than quantitatively. Therefore, knowledge of the relative risk associated with many anaesthesia-related factors is still lacking. Recently, a quantitative study of the determinants and prevention of morbidity and mortality in anaesthesia was started in the Netherlands. Its objective is to study severe peri-operative morbidity and mortality as a function of anaesthesia-related risk factors. The study is designed as a case-control study within a prospectively defined cohort. The cohort comprises all patients undergoing an anaesthetic procedure, either general, regional or a combination, in one of 61 hospitals between 1 January 1995 and 1 January 1997. A 'case' is a patient who dies within 24 h of undergoing an anaesthetic procedure or who remains comatose 24 h after an anaesthetic procedure. A 'control' patient is a randomly chosen patient who has undergone anaesthesia and is matched for gender and age. The present report discusses the study protocol.     

Evolution of trends in risk management

In the past, the detection and response to adverse clinical events were viewed as an inherent part of professionalism; and, if perceived problems were not sorted out at that level, the ultimate expression of dissatisfaction was litigation. There are now demands for the adoption of more transparent and effective processes for risk management. Reviews of surgical practice have highlighted the presence of unacceptable levels of avoidable adverse events. This is being resolved in two ways. First, attention is being directed to the extent that training and experience have on outcomes after surgery, and both appear to be important. Second, a greater appreciation of human factors engineering has promoted a greater involvement of surgeons in processes involving teamwork and non-technical skills. The community wants surgeons who are competent and health-care systems that minimize risk. In recent times attention has been focused on the turmoil associated with change; but, when events are viewed over a period of several decades, there has been considerable progress towards these ideals. Further advancement would be aided by removing the adversarial nature of malpractice systems that have failed to maintain standards.     

Surgeon and hospital volume and the management of colorectal cancer patients in Australia

BACKGROUND: The evidence for a relationship between patient outcomes and clinician and hospital volume is increasing. The National Colorectal Cancer Care Survey was undertaken to determine the management patterns in Australia for individuals newly diagnosed with colorectal cancer in a 3 month period in the year 2000. METHODS: All new cases of colorectal cancer registered at each Australian State Cancer Registry were entered into the survey. This generated a questionnaire that was sent to the treating surgeon. Chi-squared tests and logistic regression analyses were used to determine levels of statistical significance. RESULTS: Of 2,383 surgical questionnaires generated, 2,015 (85%) were completed. The majority (58%) of surgeons treated one or two patients with colorectal cancer over the 3 months of the survey. There was variation across surgeon cohorts for preoperative measures including the use of deep vein thrombosis prophylaxis. Patients seen by low volume surgeons were most likely to be given a permanent stoma (P < 0.0001). Patients with rectal cancer who were operated on by high volume surgeons were significantly more likely to receive a colonic pouch (P < 0.0001). CONCLUSION: This nationwide population-based survey of the treatment of colorectal cancer patients suggests that the delivery of care by surgeons (the majority) who treat patients with rectal cancer infrequently should be evaluated.     

Clinical governance: its effect on surgery and the surgeon

Audit is the process by which clinical staff collectively review, evaluate and improve their clinical practice with the common aim of improving standards. Modern audit has developed from the initial concept promoted in the 1980s and is now part of the concept of clinical governance. Clinical governance is a framework through which health service organizations are accountable for continuously improving the quality of their services. Clinicians have always been accountable for maintaining high quality care; clinical governance merely imposes structure in this and makes it explicit. The features of this are: (i) full participation in audit by all hospital doctors; (ii) support and use evidence-based practice, including risk management, quality assurance and clinical effectiveness; and (iii) continuing professional development.     

The Surgical Acute Care Unit (SACU): effects on surgical workload and mortality

BACKGROUND: A surgical acute care unit (SACU) is designed to provide level 1 care for surgical patients. The aim of the present study was to audit the effects of the introduction of a SACU in a teaching hospital surgical department. METHODS: A retrospective case-note audit of all admissions to the newly established SACU over the first 6 months was performed. Expected mortality and morbidity was calculated using POSSUM (physiological and operative severity score for the enumeration of mortality and morbidity) scores. Critical care data for the same period and the 6 months prior to the SACU opening was examined to determine any effect on critical care workload. RESULTS: The SACU admitted 131 patients during the audit period. There was no significant difference between predicted and observed mortality or morbidity. There was no effect on critical care length of stay after the SACU opened. Many patients who would have needed critical care beds before the SACU opened were admitted directly to the SACU after it opened. CONCLUSIONS: This audit demonstrates that the provision of a surgical acute care unit allows many patients who would normally need to be admitted to the critical care unit for postoperative care to be safely admitted to level 1 care beds.     

Physiological abnormalities in early warning scores are related to mortality in adult inpatients

Background. Early warning scores using physiological measurementsmay help identify ward patients who are, or who may become,critically ill. We studied the value of abnormal physiologyscores to identify high-risk hospital patients. Methods. On a single day we recorded the following data from433 adult non-obstetric inpatients: respiratory rate, heartrate, systolic pressure, temperature, oxygen saturation, levelof consciousness, urine output for catheterized patients, ageand inspired oxygen. We also noted the care required and given. Results. Twenty-six patients (6%) died within 30 days. Theywere significantly older than survivors (P<0.001). Theirmedian hospital stay was 26 days (interquartile range 16–39).Mortality increased with the number of physiological abnormalities(P<0.001), being 0.7% with no abnormalities, 4.4% with one,9.2% with two and 21.3% with three or more. Patients receivinga lower level of care than desirable also had an increased mortality(P<0.01). Logistic regression modelling identified levelof consciousness, heart rate, age, systolic pressure and respiratoryrate as important variables in predicting outcome. Conclusions. Simple physiological observations identify high-riskhospital inpatients. Those who die are often inpatients fordays or weeks before death, allowing time for clinicians tointervene and potentially change outcome. Access to criticalcare beds could decrease mortality. Br J Anaesth 2004; 92: 882–4     

The organizational implications of the role NHS Service Managers played in the quality process in the mid-1990s

AIM: It is the intention of this paper to highlight the problems associated with the organizational implications of the role NHS Service Managers (SMs) played in the quality process of the mid-1990s. BACKGROUND: To provide quality care all staff must be committed and involved, in this study it appeared that few SMs played a part in the process. METHODS: Semistructured taped interviews were conducted with 33 SMs and three Chief Executives in seven Trusts. As part of a study they were asked the role SMs played in quality in their clinical directorate. The data was transcribed and analysed in a content-analysis approach. FINDINGS: Quality of care was not the SMs' primary objective. The role played by SMs was dependent on their background, experience and the organization in which they worked. Most Trusts' quality-control strategy was not standardized, co-ordinated or integrated, nor was the audit process regulated. For most, quality was seen as synonymous with professions, managers from a non-professional background found the monitoring of the quality of performance inherently difficult. Only one Trust (the most successful) appeared to undertake organizational learning, influenced by the philosophy of the Chief Executive.