Bacterial colonization and infection in an intensive care unit

One hundred and one patients, nursed in an intensive care unit for at least 24h, were monitored for bacterial colonization and infection. The infection rates were similar to those in other reports. Patients were not generally colonized with common environmental strains in the unit. Bacterial dissemination between patients was uncommon. No gentamicin resistant gram negative or Staphylococcus aureus strains were observed, nor methicillin resistant Staphylococcus aureus strains. the hypothesis that these favourable conditions are partly related to the excellent isolation and barrier nursing facilities in the unit cannot be fully substantiated.     

Disturbed behaviour in dementia sufferers: A comparison of three nursing home settings

In order to determine whether a specialist psychogeriatric nursing home was fulfilling its intended role of caring for the most behaviourally disturbed dementia sufferers, 24 of its demented residents were compared with 28 demented individuals discharged from a psychiatric unit to ordinary nursing homes and 30 mobile dementia sufferers in nursing home wards of a geriatric centre. Those in the psychogeriatric nursing home showed more disturbed behaviours than those in the other two settings. Scores on the Rating Scale for Aggressive Behaviour in the Elderly were compared with degree of cognitive impairment for the first time in the literature and showed no correlation with degree of cognitive impairment for the first time in the literature and showed no correlation with congnitive performance.     

lnter-rater reliability of an oral assessment guide for elderly patients residing in a rehabilitation ward

The aim of this study was to test the inter-rater reliability of a revised oral assessment guide (ROAG) for patients residing in a geriatric rehabilitation ward. A consecutive sample of 140 patients was recruited for the study. Oral assessments were performed for 133 newly admitted patients by one registered nurse (RN) during a period of six months. A dental hygienist (DH) carried out 103 oral assessments during the same half-year. For 66 patients, the RN and the DH performed independent assessments. There was an agreement between the RN and the DH in the majority of the independent assessments, except for tongue and teeth/dentures. The percentage agreement exceeded 80 percent. Inter-rater agreement measured by Cohen's Kappa coefficient ranged from moderate to very good and percentage agreement had a range of 58 to 91 percent. The agreement was highest in assessment of voice and swallowing (91%). Assessments of teeth and dentures seemed to be most difficult for the RN to evaluate. ROAG was found to be a clinically useful assessment tool. Additional education and training is needed to improve the reliability of the oral assessments and should include continuous support from a dental hygienist as well as a pictorial manual on how to use the ROAG.     

Alfentanil or fentanyl during isoflurane–based anaesthesia for day–care knee arthroscopy?

Forty patients agreed to participate in a study to compare whether fentanyl or alfentanil used as analgesic is associated with quicker recovery following anaesthesia for outpatient arthroscopy procedure. Psychomotor tests including choice reaction time (CRT), perceptive accuracy test (PAT) and finger tapping test (FTT) were done prior to induction of anaesthesia with propofol (2–3 mg–kg^-1). Patients were then divided into two groups: Group F (fentanyl) received 0.1 mg fentanyl prior to start of surgery and thereafter 0.05 mg every 30 min during the procedure. Group A (alfentanil) received 0.5 mg alfentanil prior to the onset of surgery and 0.25 mg every 15 min thereafter. Anaesthesia was then maintained using isoflurane (0.5–2%) in oxygen and air (Fio₂ 0.33) during spontaneous respiration with a face mask in a Bain's system. Psychomotor tests were repeated every 45 min postoperatively. Clinical recovery, visual analogue pain intensity score (VAS) and time to discharge home were also assessed by a nurse blind to the method used. Patients in Group A returned to baseline values on the FTT after 90 min while those in Group F did not return to baseline values until 135 min after the end of the operation. Clinical recovery and time to discharge home ("home ready") were also significantly longer in Group F. There was no difference in recovery as seen in the PAT and CRT between the groups. Also, there was no difference in the incidence of side effects and the pain intensity (VAS) scores were similar in the two groups at all time periods. We conclude that recovery following alfentanil is quicker compared to fentanyl when anaesthesia is based on isoflurane.     

Glutamine and Other Amino Acid Losses During Continuous Venovenous Hemodiafiltration

Abstract: Serum amino grams and daily losses of glutamine (Gin) and other amino acids (AAs) into diafiltrate were measured during the first 5 days of continuous venovenous hemodiafiltration (CVVHDF) in 6 ICU patients with acute renal failure (ARF). Four patients had ARF as a part of multiple organ failure (MOF) of septic origin, and 2 patients had isolated ARF because of primary renal disease. During the study, all the patients received defined total parenteral nutrition (TPN). The mean daily AA losses into dialysate were relatively low (0.61 ± 0.1 g N ) and reached 4.5% of the daily AA substitution. Gln represented 32.7 ± 5.9% of the total AA losses (0.19 ± 0.04 g N ). Serum levels of Gin (p = 0.002) and of most other AAs were significantly lower in the patients than in the control subjects (AA analysis in 16 healthy volunteers). Phenylalanine (Phe) was the only AA that was increased significantly (p < 0.01) in the patients. The mean patient serum concentrations of Phe and tyrosine were significantly higher (p < 0.03) than the correspondent concentrations in dialysate, but the lysine concentration was higher in dialysate (p < 0.03). The serum and dialysate concentrations of other AAs did not differ. Gin in serum decreased significantly (p < 0.03) on the second day of CVVHDF but returned to the baseline levels subsequently. Serum concentrations of Phe increased on the second day of CVVHDF (p < 0.05). Serum concentrations of other AAs remained stable during the whole study. We conclude that Gin losses into dialysate during CVVHDF are relatively low, but CVVHDF itself may induce changes in Gin metabolism and distribution that are reflected by a decrease of serum Gin levels at the institution of this treatment. Therefore, the need for Gin supplementation in ICU patients is even greater in the first days of CVVHDF.     

The potential of an anaesthesiologist–manned ambulance service in a rural/urban district

The use of anaesthesiologists in prehospital emergency care is controversial. We wanted to assess the impact of an anaesthesiologist and a short time interval from acceptance of a mission to take–off at survival rates in a rural/urban emergency medical service. Prospectively registered data for 991 consecutive patients through a 12–month period were retrospectively evaluated by an independent foreign expert. Of all primary missions, 3.3% were considered probably lifesaving from site of injury to receiving hospital. Of these, the lifesaving result in 50% were dependent on both the qualifications of the anaesthesiologist and a short response time. Survival from hospital admission to discharge was 44%. All patients were discharged to their own homes, able to live a fully functional life. The consistent use of anaesthesiologists compared to less qualified personnel and the maintaining of response times below presently required minima doubles the potential for lives saved in services comparable to the one studied.     

Development of quality of care indicators for Parkinson's disease.

Parkinson's disease (PD) is a major cause of disability. To date, there have been no large-scale efforts to measure the quality of PD care because of a lack of quality indicators for conducting an explicit review of PD care processes. We present a set of quality indicators for PD care. Based on a structured review of the medical literature, 79 potential indicators were drafted. Through a two-round modified Delphi process, an expert panel of seven movement disorders specialists rated each indicator on criteria of validity, feasibility, impact on outcomes, room for improvement, and overall utility. Seventy-one quality indicators met validity and feasibility thresholds. Applying thresholds for impact on outcomes, room for improvement, and overall utility, a subset of 29 indicators was identified, spanning dopaminergic therapy, assessment of functional status, assessment and treatment of depression, coordination of care, and medication use. Multivariable analysis showed that overall utility ratings were driven by validity and impact on outcomes (P < 0.01). An expert panel can reach consensus on a set of highly rated quality indicators for PD care, which can be used to assess quality of PD care and guide the design of quality improvement projects.