Impact of medical practice guidelines on the assessment of patients with acute coronary syndrome without persistent ST segment elevation.

OBJECTIVE: To assess the impact of introducing clinical practice guidelines on acute coronary syndrome without persistent ST segment elevation (ACS) on patient initial assessment. DESIGN: Prospective before-after evaluation over a 3-month period. SETTING: The emergency ward of a tertiary teaching hospital. PATIENTS: All consecutive patients with ACS evaluated in the emergency ward over the two 3-month periods. INTERVENTION: Implementation of the practice guidelines, and the addition of a cardiology consultant to the emergency team. MAIN OUTCOME MEASURES: Diagnosis, electrocardiogram interpretation, and risk stratification after the initial evaluation. RESULTS: The clinical characteristics of the 328 and 364 patients evaluated in the emergency ward for suspicion of ACS before and after guideline implementation were similar. Significantly more patients were classified as suffering from atypical chest pain (39.6% versus 47.0%; P = 0.006) after guideline implementation. Guidelines availability was associated with significantly more formal diagnoses (79.9% versus 92.9%; P < 0.0001) and risk stratification (53.7% versus 65.4%, P < 0.0001) at the end of initial assessment. CONCLUSION: Guidelines implementation, along with availability of a cardiology consultant in the emergency room had a positive impact on initial assessment of patients evaluated for suspicion of ACS. It led to increased confidence in diagnosis and stratification by risk, which are the first steps in initiating effective treatment for this common condition.     

Using case management in a universal health coverage system to improve quality of life of frequent Emergency Department users: a randomized controlled trial

Purpose

Frequent Emergency Department users are likely to experience poor quality of life (QOL). Case management interventions are efficient in responding to the complex needs of this population, but their effects on QOL have not been tested yet. Therefore, the aim of our study was to examine to what extent a case management intervention improved frequent Emergency Department users’ QOL in a universal health coverage system.

Methods

Data were part of a randomized controlled trial designed to improve frequent Emergency Department users’ QOL at the Lausanne University Hospital, Switzerland. A total of 250 frequent Emergency Department users (≥?5 attendances during the previous 12 months) were randomly assigned to the control (n?=?125) or the intervention group (n?=?125). The latter benefited from case management intervention. QOL was evaluated using the WHOQOL-BREF at baseline, two, five and a half, nine, and twelve months later. It included four dimensions: physical health, psychological health, social relationship, and environment. Linear mixed-effects models were used to analyze the change in the patients’ QOL over time.

Results

Patients’ QOL improved significantly (p?<?0.001) in both groups for all dimensions after two months. However, environment QOL dimension improved significantly more in the intervention group after 12 months.

Conclusions

Environment QOL dimension was the most responsive dimension for short-term interventions. This may have been due to case management’s assistance in obtaining income entitlements, health insurance coverage, stable housing, or finding general health care practitioners. Case management in general should be developed to enhance frequent users’ QOL.Trial registration: http://www.clinicaltrials.gov, Unique identifier: NCT01934322

     

Impact of a computerized information system on quality of nutritional support in the ICU

OBJECTIVE: In intensive care units (ICUs), patient outcome depends on quality of nutritional support. We investigated the effect of computerized information systems (CISs) on quality of nutritional support by comparing two ICUs with or without CIS and burned patients before and after CIS implementation. METHODS: Part 1 was a 2-wk prospective survey in two units of a surgical ICU: unit A (11 beds) without CIS and unit B (four beds) with CIS. Part 2 consisted of two 18-mo periods in burn patients before and after CIS implementation. Nurses and doctors belonged to the same team; procedures were identical. A computer page was configured to retrieve data related to nutritional support. RESULTS: A total of 1313 ICU days were analyzed in 109 patients. Patients' characteristics were similar in parts 1 and 2. In part 1, nutritional support was required 38% of days. Nutritional route was similar but data were more frequently missing in unit A. Energy delivery was higher with CIS but below target values in both units (31+/-11% of target in unit A, 77+/-4% in unit B). Computations were incomplete and time consuming for unit A versus B (11+/-2 versus 2+/-1 min/patient, P<0.0001). In part 2, in the 54 burn patients, use of postpyloric feeding tubes and energy delivery increased with CIS, resulting in less weight loss. CONCLUSION: Computerized information systems favored standardization of nutritional care and monitoring, thus decreasing time required for writing and computations. Follow-up was improved and nutrient delivery was closer to target values, thus increasing quality of care. In burn patients, the better data visibility was associated with a significant improvement in nutrient delivery.     

Impact of an intervention to control risk associated with patient transfer

QUESTION UNDER STUDY: Hospitals transferring patients retain responsibility until admission to the new health care facility. We define safe transfer conditions, based on appropriate risk assessment, and evaluate the impact of this strategy as implemented at our institution. METHODS: An algorithm defining transfer categories according to destination, equipment monitoring, and medication was developed and tested prospectively over 6 months. Conformity with algorithm criteria was assessed for every transfer and transfer category. After introduction of a transfer coordination centre with transfer nurses, the algorithm was implemented and the same survey was carried out over 1 year. RESULTS: Over the whole study period, the number of transfers increased by 40%, chiefly by ambulance from the emergency department to other hospitals and private clinics. Transfers to rehabilitation centres and nursing homes were reassigned to conventional vehicles. The percentage of patients requiring equipment during transfer, such as an intravenous line, decreased from 34% to 15%, while oxygen or i.v. drug requirement remained stable. The percentage of transfers considered below theoretical safety decreased from 6% to 4%, while 20% of transfers were considered safer than necessary. A substantial number of planned transfers could be "downgraded" by mutual agreement to a lower degree of supervision, and the system was stable on a short-term basis. CONCLUSION: A coordinated transfer system based on an algorithm determining transfer categories, developed on the basis of simple but valid medical and nursing criteria, reduced unnecessary ambulance transfers and treatment during transfer, and increased adequate supervision.     

Structural and thermal characterization of glyceryl behenate by X-ray diffraction coupled to differential calorimetry and infrared spectroscopy

Physical and thermal properties of glyceryl behenate (Compritol 888 ATO) used as sustained-release matrix in pharmaceutical applications are studied by coupled time-resolved synchrotron X-ray diffraction and Differential Scanning Calorimetry combined with Infrared Spectroscopy. With these techniques, all polymorphs formed in glyceryl behenate, analyzed as received and after various thermal treatments from quenching to slow crystallization, are characterized. By using different well-controlled mixtures of mono-, di- and tribehenate, we identify each lamellar phase observed in the glyceryl behenate. Finally the influence of the crystallization rate on the formation of preferential conformations was also analyzed in order to bring insights into the polymorphism of glyceryl behenate. By changing the crystallization rate of the sample, it was shown that one can favor the formation of preferential polymorphs in the sample. In particular the crystallization at 10 degrees C/min seems to be well adapted for producing a single lamellar phase with a period of 60.9 A while a crystallization rate of 0.4 degrees C/min produces three different lamellar phases.     

An economic analysis of hormone replacement therapy for the prevention of fracture in young postmenopausal women

Osteoporosis is a major public health problem that will become increasingly important as our population ages. It leads to fractures that deeply affect the patients' quality of life. Osteoporosis is recognised as a leading factor in healthcare cost worldwide. For years, experts have recommended hormone replacement therapy (HRT), consisting of oestrogen with or without progestin, as the first-line therapy to prevent bone loss in postmenopausal women. Recently published randomised, controlled trials and well-designed meta-analyses confirm that HRT has both advantages and disadvantages. The advantages include prevention of osteoporotic fractures and colorectal cancer. The disadvantages are the resulting adverse effects such as coronary artery disease, stroke, thromboembolic events, breast cancer and cholecystitis. In the light of these findings, medical associations recommend against the routine use of oestrogen and progestin for the prevention of chronic conditions in postmenopausal women. HRT, administered for the prevention of fractures in all young postmenopausal women, would have an additional cost/year of life gained that is too expensive. However, this strategy seems to be cost-effective when young postmenopausal women at high risk for fractures are selected. Even if this strategy seems attractive, the adverse effects of HRT are not acceptable. This situation implies that other treatments must be found to prevent or treat osteoporosis. Among them, calcium and vitamin D were shown to be cost-saving in osteoporosis and even costs-effective in osteopoenia in young postmenopausal women.