Quality assurance in the emergency department

A coordinated approach to quality assurance is essential for managing the complexities of health care in the emergency department. Nearly every activity in the emergency care setting has implications that fall under the quality assurance umbrella. A comprehensive quality assurance program for the emergency department at Michael Reese Hospital was built through a process of defining, further developing, and coordinating existing quality assurance activities. Several new activities were developed to fill identified gaps. The program follows traditional quality assurance concepts for monitoring structure, process, and outcome elements of emergency care. Key principles that are the foundation of the program include active participation by all staff levels (clinical and nonclinical), standardized documentation, and specifically defined review mechanisms.     

Drug-involved women as potential users of vaginal microbicides for HIV and STD prevention: a three-city survey

We wished to obtain potential users' perspectives on vaginal microbicides from a population of women at high risk for HIV. We conducted a face-to-face survey of convenience samples (total n = 743) of drug-using women and female sexual partners of male injection drug users in Bridgeport, Connecticut, Providence, Rhode Island, and San Juan, Puerto Rico. Ninety percent of respondents said that they would be very likely to use microbicides with paying partners and 78% with primary partners (p = 0.001). High hypothetical likelihood of use was expressed even after several potential product characteristics (e.g., causes minor vaginal irritation or burning) were rated as unacceptable. Latinas had significantly higher predicted likelihood of use with primary (p = 0. 001) and paying partners (p = 0.018) than blacks and whites. Eighty percent of respondents preferred products that enhance sexual pleasure by providing additional lubrication or "wetness." More than 80% of respondents said that they would want their primary partners to know of their microbicide use, and 42% (p = 0.001) said that they would want their paying partners to know. Women's concern about a paying partner's violent response to suggested use of risk reduction measures was inversely related to predicted likelihood of microbicide use (p = 0.045). Microbicides should be assessed in the context of the potential users' actual relationships and cultures. Achieving broad acceptability among drug-involved women will require a range of products.     

Community attitudes toward HIV prevention for injection drug users: Findings from a cross-border project in southern China and northern Vietnam

Success of HIV prevention projects for injection drug users (IDUs) depends on the support of the communities in which they are implemented. This article presents data from cross-sectional community surveys of HIV knowledge and attitudes toward peer-based HIV prevention interventions for injection drug users in a border area of Lang Son Province, Vietnam and Ning Ming County, Guangxi Province, China. Analysis of these surveys at baseline and 18 months reveals generally high or improving levels of HIV knowledge and positive attitudes toward the interventions in both Vietnam and China. Levels of knowledge and positive attitudes tended to be higher in Vietnam than in China. Interviews with staff and peer educators suggest that the project’s community education efforts have increased support for the interventions and contributed to their smooth implementation. However, the community surveys also reveal some continuing deficits in HIV knowledge and understanding of the interventions, including perceptions that provision of new needles/syringes will result in increased drug use. Additional education, including dissemination of countervailing project data, is necessary to address these deficits and further increase community support for the interventions.     

Acceptability of formulations and application methods for vaginal microbicides among drug-involved women: results of product trials in three cities

BACKGROUND AND OBJECTIVES: Female-controlled methods of HIV prevention, such as vaginal microbicides, are urgently needed, particularly among drug-involved women. Acceptability research is critical to product development. GOAL: To assess the acceptability of forms and application methods for future microbicides. DESIGN: Eighty-four drug-involved women were introduced in groups to three lubricant products, asked to try each for 3 weeks, and scheduled for individual follow-up interviews. RESULTS: Participants and their partners felt positive about the products, and expressed willingness to use microbicides if they were shown to be effective against HIV. Women agreed on product characteristics that influenced their reactions (e.g. ease of insertion, degree of "messiness"), but often disagreed on whether their reactions to these characteristics were positive or negative. CONCLUSION: Development of acceptable and effective HIV-prevention products depends on understanding the interaction between characteristics of the products and the characteristics and perceptions of women. Levels of sexual risk and acceptability factors based on drug-use patterns, race and ethnicity, culture, age, and types and attitudes of male partners suggest that a "one size fits all" approach will not win broad acceptance among drug-involved women.     

Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail. The results of 52 procedures

BACKGROUND: The purpose of this study was to report the results of 52 combined subtalar and ankle arthrodesis using an intramedullary nail. METHODS: Retrospective review identified 49 patients who had 52 combined ankle and subtalar arthrodeses with an ACE retrograde locked intramedullary humeral nail (DePuy-Ace), Warsaw, IN). Most procedures included bone grafts from the fibula, proximal tibia, or iliac crest or femoral head allograft. Intraoperative complications included one fractured tibia and one fractured medial malleolus. The procedure was done mainly for the treatment of combined ankle and subtalar arthritis (31) or complex hindfoot deformities (12). Outcome was assessed by a combination of chart review, clinical examination, and telephone questionnaire. Followup averaged 34 (8 to 73) months. RESULTS: At followup 82% of patients were satisfied with the results of surgery, 82% reported improvements in pain levels, and 67% reported improved foot function. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 63. Postoperative complications included deep infection, amputation, stress fracture, nonunion, and prominent hardware. CONCLUSION: Hindfoot arthrodesis with intramedullary nailing is an effective technique for treating complex foot deformities and often is the only alternative to amputation. Patient satisfaction is high, but the procedure is demanding and complications are frequent.