A modification of the POSSUM surgical audit system for the minimally invasive therapy community

Summary

The POSSUM system has the potential to be the universally accepted basic surgical audit system. Some modifications are suggested to enhance POSSUM'S sensitivity.     

Use of red blood cell transfusions in surgery

Background: Limited blood supplies necessitate the rational use of blood products. The aim of the present study was to provide a basis for audits of red cell usage in surgery by benchmarking common practice. Application of the data to the construction of a maximum surgical blood order schedule may be relevant for centres that perform a serological crossmatch or who collect autologous units. Methods: Data on surgical procedures identified by Commonwealth Medical Benefits Schedule item numbers, were collected retro­spectively from theatre and blood bank records at the Royal Melbourne and Melbourne Private hospitals from May 1997 to April 1998. The percentage of procedures for which red cells were transfused, and the mean, median and range of units transfused for procedures with ≥ 30% transfusion likelihood were identified. Results: Over 12 months, 266 surgical procedure codes were itemized ≥ 10 times each, contributing 12 300 data entries. Only 38 procedures demonstrated an incidence of transfusion of at least 30%. Most frequently transfused procedures included spinal fusion, total hip replacement, mandible/maxilla resection, prostatectomy and bladder excision. Conclusion: The number of common surgical procedures in which there is a 30% or greater likelihood that red cell transfusions will be given is limited. This benchmarking of common red cell usage is a first step in the process of determination of transfusion appropriateness.     

医院伦理委员会的建设与临床试验的伦理审核

通过对卫生部北京医院伦理委员会建设和伦理审核工作的组织建设、制度建设、人员培训、工作状况等的分析，阐明伦理审核工作的意义、体会及需要进一步研究和探索的问题。     

国家、社会与内部三种审计合力探索及在卫生健康系统中的应用

在阐明了国家审计、社会审计和内部审计形成合力是党和国家战略决策的基础上,进一步明确国家审计、社会审计和内部审计的职能定位,探索三种审计的各自优势与局限以及形成合力的可行性、必要性,再通过国家卫生健康系统的相关实践,最终提出构建国家审计、社会审计和内部审计合力机制的建议.     

Effectiveness and safety of insulin glargine in the therapy of complicated or secondary diabetes: clinical audit

Abstract We wanted to assess the effectiveness and safety of glargine in the treatment of patients with type 2 diabetes mellitus in secondary failure and/or with severe comorbidities (“T2DM group”), and patients with secondary diabetes after corticosteroid and/or anticancer treatment (“secondary DM group”). We reviewed the records of patients on glargine from 1 August 2004 to 30 July 2005. The after-minus-before change in HbA_1c was the main outcome measure. At baseline, the 18 “T2DM” patients had a mean (±SD) age of 66.7±9.5 years and a diabetes duration of 13.6±10.3 years; 52.9% were male. Their fasting plasma glucose (FPG) decreased from 228.6±76.6 to 134.6±37.5, two-hour post-prandial glycaemia (2hPPG) from 268.2±10.4 to 140.6±30.8 and HbA_1c from 10.4±2.3 to 7.9±1.6%. Mean daily insulin dosage was 12.0±4.8 UI for glargine alone and 37.4±22.6 UI for basal-bolus scheme. The daily cost was € 0.75 (range € 0.31–1.15). The 24 “secondary DM” patients had a mean age of 67.0±11.0 years and a diabetes duration of 3.7±6.5 years; 54.2% were male and 91.7% had a metastatic cancer. Their FPG decreased from 222.3±108.6 to 121.5±28.7 mg/dl, 2hPPG from 259.4±108.6 to 133.0±35.0 mg/dl and HbA1c from 10.1±2.5 to 7.6±1.3%. Mean daily insulin dosage was 12.5±6.1 UI for glargine alone and 27.2±9.1 UI for basal-bolus scheme. Mean daily cost was € 0.70 (range € 0.31–1.38). One (4.2%) cancer patient withdrew from glargine because of nausea. Nine (37.5%) cancer patients had an increase in appetite after glargine therapy, including 3 end-of-life patients. No severe hypoglycaemia occurred. Insulin glargine was safe and effective in improving glycaemic control both in severe “T2DM” and in “secondary DM” patients.     

总责任护士主导的医护一体化护理模式在创伤骨科的应用

目的探讨总责任护士主导的医护一体化临床护理模式在创伤骨科的应用效果。 方法选择2016年7月至2017年6月在南京大学医学院附属鼓楼医院创伤骨科行手术治疗的骨折患者200例,按照入院先后顺序分为对照组90例(实施创伤骨科常规护理)和观察组110例(实施医护一体化工作模式,包括成立医护合作小组、实施总责任护士主导的医护一体化查房、个体化诊疗方案的共同决策、疼痛管理、早期出院计划与延续护理)。比较2组患者的术后护理效果和医护合作满意度。对数据行t检验和χ²检验。 结果总责任护士主导的医护一体化模式下,观察组患者术后72 h内数字评分法(NRS)评分为(4.09±1.64)分,疼痛干预有效率为77.57%,对照组术后72 h内NRS评分为(5.15±1.69)分,疼痛干预有效率为57.95%,2组比较差异均有统计学意义(P值均小于0.05);观察组下肢深静脉血栓、泌尿系统感染、便秘的发生例数分别为2、1、3,对照组下肢深静脉血栓、泌尿系统感染、便秘的发生例数分别为9、7、11,两组比较差异均有统计学意义(χ²＝4.486、4.296、6.812,P＝0.027、0.036、0.009)。观察组术后康复开始时间为(21.48±6.41)h,术后住院时间为(11.08±2.19)d;对照组术后康复开始时间为(36.48±10.75)h,术后住院时间为(13.95±2.93)d,2组比较差异均有统计学意义(t＝11.670、－7.616,P值均小于0.05)。2组医护合作满意度结果显示,观察组患者信息的交流得分为(3.78±0.85)分,共同参与治疗或护理决策得分为(3.86±0.87)分,医师和护士的关系得分为(4.00±0.84)分,总分为(3.87±0.67)分;对照组患者信息的交流得分为(3.32±1.00)分,共同参与治疗或护理决策得分为(3.23±0.93)分,医师和护士的关系得分为(3.45±0.96)分,总分为(3.33±0.84)分,2组比较差异均有统计学意义(P值均小于0.05)。 结论总责任护士主导的医护一体化护理模式的应用,以亚专科为核心,重新整合医护资源,共同参与制订患者的诊疗护理方案,共同聚焦患者安全与质量,加强了医护间的配合,提高了医疗护理服务质量,提升医护合作满意度。     

British HIV Association (BHIVA) national cohort outcomes audit of patients commencing antiretrovirals from naïve

Objectives

The aim of this work was to audit the extent to which routine HIV care in the UK conforms with British HIV Association (BHIVA) guidelines and specifically the proportion of patients starting highly active antiretroviral therapy (HAART) who achieve the outcome of virological suppression below 50 HIV‐1 RNA copies/mL within 6 months.

Methods

A prospective cohort review of adults with HIV infection who started antiretroviral therapy (ART) for the first time between April and September 2006 was carried out using structured questionnaire forms.

Results

A total of 1170 adults from 122 clinical sites participated in the review. Of these patients, 699 (59.7%) started ART at CD4 counts <200 cells/μL and 193 (16.5%) had not been tested for HIV drug resistance. Excluding patients with valid reasons for stopping short‐term ART, 795 (73.5%) of 1081 patients had an undetectable viral load (VL) at follow‐up. Detectable VL was strongly associated with pretreatment CD4 count below 50 cells/μL and pretreatment VL above 100 000 copies/mL, and was not associated with clinic location or case load. About a quarter of patients did not have a VL measurement during the first 6 weeks after starting ART.

Conclusions

The majority of patients who initiated ART at sites participating in this UK national audit were managed within the BHIVA guidelines and achieved virological suppression below 50 copies/mL around 6 months after commencing treatment. Poor VL outcomes were associated with very low CD4 cell count and/or high VL at baseline but not with clinic case load or location. There is an urgent need to diagnose patients at an earlier stage of their HIV disease.