Implementation of a pre-hospital decision rule in general practice: Triage of patients with suspected myocardial infarction

OBJECTIVE: To improve pre-hospital triage of patients with suspected acutecardiac disease DESIGN: Prospective study SUBJECTS: Patients with symptoms suggestive of acute cardiac pathology,who were seen by a general practitioner, for whom acute admissioninto hospital was requested, and in whom a pre-hospital electrocardiogramwas recorded by the ambulance service METHODS: The study consisted of two phases. In the first phase, a decisionrule was developed based on clinical characteristics and electrocardiographicfindings in 1005 patients with suspected acute cardiac pathology.In the second phase, the decision rule was prospectively validated.Symptoms were recorded by a standardized questionnaire by thegeneral practitioner and a computerized electrocardiogram wasmade by the ambulance nurses at the patient's home. Three electrocardiographicoutcomes were available: ‘normal electrocardiogram’,‘possible myocardial infarction’ or ‘extensivemyocardial infarction’. By use of the predictive model,the general practitioner could decide if hospitalization wasnecessary or not. MAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chestpain, other pathology) and high (myocardial infarction, unstableangina) probability of acute cardiac pathology. RESULTS: Among 977 patients with a complete pre-hospital evaluation inthe validation phase of the study, the decision rule recommended‘no hospitalization’ in 227 patients (23%). Thegeneral practitioner followed this advice in 44% of these patients.Although seven of them developed a non-Q wave myocardial infarction,no complications occurred in patients not admitted. In addition,the general practitioner did not hospitalize 19 (2%) of 750patients for whom the decision rule recommended admission. Prehospitaltriage by the general practitioner resulted in a 12% (118 of977 patients) reduction of the number of patients admitted tothe Coronary Care Units. CONCLUSIONS: Pre-hospital triage by the general practitioner was facilitatedusing a standardized questionnaire and pre-hospital electrocardiography,and resulted in a reduction in the number of patients admittedto the Coronary Care Unit, and proved to be safe.     

Special Hospital seclusion and its clinical variations

Summary

• ? The terminology used in the published literature to indicate that a patient is being denied, or is denying themself, the company of other people is wide and varied.
• ? With ever growing concerns of the rights, both civil and legal, of patients receiving treatment, either solicited or unsolicited, there is a need to identify the patterns of practice in any given organization and to establish their relationship to the terminological semantic.
• ? The Special Hospitals, who cater for those patients requiring a high degree of security, have been assumed to use seclusion to a greater degree than any other form of personal-space facility, either forced by the staff or elected by the patient. However, this has largely been based on hearsay and speculation.
• ? Seclusion may be perceived as a clinical psychiatric intervention to prevent the serious deterioration of a person's mental state or as a method of containment of a dangerous situation when all else fails.
• ? This study was based on a survey of all seclusion facilities within the Special Hospital system and discussions with over 100 nursing staff about the differing types and methods of providing patient withdrawal from the ward community for whatever reason.
• ? The results highlighted a clear uniformity of practice throughout the system despite the differing terminologies used.

     

Detection of contamination with antineoplastic agents in a hospital pharmacy department

The contamination with fluorouracil, cyclophosphamide and methotrexate was studied in a hospital pharmacy department where these drugs were prepared. In the preparation room, air samples were taken before and during preparation of the drugs. Methotrexate was detected in one sample which was collected during preparation (0.3g/m³). Spot samples were taken in the vertical laminar airflow safety hood before and after preparation of the drugs and after cleaning of the hood. Contamination of the laminar airflow hood was: cyclophosphamide: 1–160 ng/cm²; fluorouracil: 10–62 ng/cm² and methotrexate: 2–633 ng/cm². Spot samples from the floor in front of and beneath the laminar airflow hood showed contamination with especially fluorouracil (48–236g/m²). The gloves used during preparation of the drugs were contaminated mainly with fluorouracil (5–980 ng/cm²). Urine samples from two workers involved in the preparation of the drugs were analysed for unmetabolized cyclophosphamide; it was not detected. Although no uptake of cyclophosphamide was established, it is shown that the methods for measurement of cyclophosphamide, fluorouracil and methotrexate in the preparation room are applicable for the control of occupational exposure to these drugs.     

The characteristics of suicide attempters admitted to the main general hospital in Fiji Islands

Objective: To study the characteristics of suicide attempters attending the main general hospital in Fiji Islands. Method: Consecutive suicide attempters were clinically evaluated, and their sociodemographic and clinical characteristics were compared with those of other patients seen in the psychiatric service between January 15, 1999 and January 14, 2000. Results: Thirty-nine suicide attempters were seen, representing 36.8% of all the cases referred to the psychiatric service. The prevalence of attempted suicide in the Greater Suva Area was 34.8 per 100,000. Majority (56.4%) were young (16–25 years), Indians (59%), female (61.5%), students (41%), never married (74.4%) and of Hindi faith (48.7%). The commonly used methods were ingestion of drugs and pesticides. The intention to die was present in 20 (51.3%) of the population. Social problems and/or psychiatric comorbidity were present in over 60% of cases. Suicide attempters were significantly younger, more of single persons (P<.0001), and fewer were in employment (P<.001) than nonsuicidal cases seen. The difference was not significant when the two groups were compared regarding gender, race or religion. Conclusions: Young people attempt suicide in disturbed psychosocial milieu, using available poisoning methods with strong desire to die. Apparently, high proportion of female Indians in this group reflects high rate of service utilization by them. Unemployment is an insignificant predisposing factor.     

头孢吡肟治疗围术期医院获得性肺炎

目的　观察头孢吡肟治疗骨科围术期医院获得性肺炎的疗效及安全性 ,并与头孢他啶进行比较。方法　骨科围术期医院获得性肺炎 70例随机分为两组 :头孢吡肟组 3 5例 ,静滴 1.0～ 2 .0g ,2次 /d ;头孢他啶组 3 5例 ,静滴 1.0～ 2 .0g ,2次 /d ;两组均治疗 1～ 2周。结果　头孢吡肟组及头孢他啶组临床有效率分别为 94.2 9%及 91.43 % (P >0 .0 5 ) ,细菌清除率分别为 94.12 %及 90 .91% (P >0 .0 5 ) ,不良反应发生率均为 2 .86% (P >0 .0 5 )。结论　头孢吡肟治疗骨科围术期医院获得性肺炎的疗效显著而又安全     

利用医院集中监测药物不良反应管理系统适时监测药物性肝损害

目的 :研究利用医院集中监测药物不良反应管理系统监测药物性肝损害的方法。方法 :应用自制程序 ,从医院住院患者数据库中提取2001年12月～2002年2月丙氨酸氨基转移酶、门冬氨酸氨基转移酶和总胆红素异常的住院患者资料 ,并进行回顾性与适时性分析。结果 :可能涉及药物不良反应的有50例 ,相关药物有11类、30种 ;属不合理用药的有11例 ,相关药物有10种。结论 :通过这种方法可及时获得药物性肝损害发生的信息 ,同时这也为医院集中开展药物不良反应监测提供了一种新的思路。     

慢性阻塞性肺疾病继发院内真菌感染的危险因素及药物经济学分析

目的 :分析慢性阻塞性肺疾病 (COPD)急性加重期继发院内深部真菌感染的危险因素及其药物治疗的经济学意义。方法 :查阅 2 0 0 0年 10月～ 2 0 0 1年 10月我院 74例COPD急性加重期患者的病历 ,对其抗生素应用种类、应用时间、糖皮质激素应用情况、真菌感染部位、菌种类型、抗真菌药物、住院费用及平均住院日进行分析。结果 :高龄及营养状况差是院内真菌感染的危险因素之一 ,而广谱抗生素长期大量应用则是造成真菌感染的重要因素 ,另外 ,合并应用糖皮质激素也是院内真菌感染的又一发病因素。继发院内真菌感染 ,明显延长了住院时间 ,增加了住院费用。结论 :减少院内真菌感染 ,对遏制医疗费用的增长 ,节约国家的卫生资源 ,具有重大意义     

驻店执业药师与医院医师优势合作的SWOT分析

目的 :促进我国驻店执业药师与医院医师的合作。方法 :运用SWOT分析方法 ,分别对驻店执业药师和医院医师各自的优、劣势以及各自所处环境的机会、威胁进行分析。结果与结论 :我国驻店执业药师和医院医师应各司其职、相互交流、共同协作 ,一起服务于我国的卫生保健事业。     

解放军302医院药学部防治SARS应急预案

为进一步做好SARS的预防和控制，切实有效地保障解放军302医院药品供应工作，我院制定了SARS的应急预案，并付诸实施，旨在提高药学部对于突发公共卫生事件的快速反应能力和应急处理能力。     

Hospital-related differences in breast cancer management

A retrospective review is presented of 1353 consecutivepatients with histopathologically confirmed invasive breast carcinoma treatedradically with curative intent during the decade 1980–89.None had received adjuvant systemic therapy with hormonesor prolonged chemotherapy. The distribution of lymph-node negative(N–) and lymph-node positive (N+) patients was 75%and 25%, respectively.The treatment and outcome were analysed as regardsconventional prognostic parameters, in particular considering the axillarylymph-node status and the responsible hospital category (GeneralMunicipal Hospitals (MH)) versus Comprehensive Cancer Center (CC)).The most striking difference was detected as regardsthe number of examined lymph nodes. The mediannumber of nodes described at the MH was7, as compared to 14 at the CC(p < 0.001). In patients with pT1 tumoursthe highest rate of lymph-node positivity was observedwhen 10 or more axillary nodes were removed.Adjuvant radiotherapy reduced the loco-regional recurrence rate inthe N– patients, whereas only the regional recurrenceswere reduced among the N+ patients. The five-and 10-year tumor-related survival rates were 86% and76%, respectively, with no difference between the MHand the CC.As life-prolonging adjuvant hormone therapy and chemotherapy isnow available for patients with axillary lymph nodemetastases, it is important that patients with breastcancer are operated adequately with the aim toremove at least 10 axillary lymph nodes. Athorough examination of the axillary content should beperformed by the pathologist, and the number ofresected lymph nodes and metastases should be reported.The establishment of nation-wide standard criteria for themanagement of breast cancer is recommended.