Apr 182014
 
Related Articles

Developing a hospital quality improvement initiative in Lesotho.

Int J Health Care Qual Assur. 2014;27(1):15-24

Authors: Berman J, Nkabane EL, Malope S, Machai S, Jack B, Bicknell W

Abstract
PURPOSE: Hospital-based quality improvement (QI) programs are becoming increasingly common in developing countries as a sustainable method of strengthening health systems. The aim of this paper is to present the results and lessons learned from a QI program in a large, rural, district hospital in Lesotho, Southern Africa.
DESIGN/METHODOLOGY/APPROACH: Over a 15-month period, a locally-relevant, hospital-wide QI program was developed and implemented. The QI program consisted of: planning meetings with district and hospitals staff; creation of multi-disciplinary QI teams; establishment of a QI steering committee; design and implementation of a locally appropriate QI curriculum; and monthly consultation from technical advisers. Initial QI programming was developed in three distinct areas: maternity care, out-patient care, and referral systems.
FINDINGS: Partogram documentation in the maternity department increased by 78 percent, waiting time for critically ill patients in the out-patient department was reduced by 84 percent, and emergency referral times were reduced by 58 percent.
ORIGINALITY/VALUE: The design and early implementation of QI programs should focus on easily achievable, locally-relevant improvement projects. It was found that early successes helped to fuel further QI gains and the authors believe that the work building sustainable QI skill sets within hospital staff could be useful in the future when attempting to tackle larger national-level quality of care indicators. The findings add to the existing evidence suggesting that an increased use of locally-relevant quality improvement programming could help strengthen health care systems in low resource settings.

PMID: 24660514 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Share


Apr 182014
 
Related Articles

Severe sepsis in the emergency department - an observational cohort study from the university hospital of the West Indies.

West Indian Med J. 2013 Mar;62(3):224-9

Authors: Edwards R, Hutson R, Johnson J, Sherwin R, Gordon-Strachan G, Frankson M, Levy P

Abstract
OBJECTIVE: To describe the incidence, treatment and outcomes of patients with severe sepsis and septic shock in a setting where early goal directed therapy (EGDT) is not routinely performed.
METHOD: An observational study of all adult patients admitted from the emergency department (ED) of the University Hospital of the West Indies (UHWI) with a diagnosis of severe sepsis and septic shock from July 5, 2007 to September 1, 2008 was conducted. Baseline parameters, treatment patterns and in-hospital outcomes were evaluated.
RESULTS: A total of 58 011 patients were seen and 762 (1.3%) had sepsis, 117 (15.4%) of whom were classified as severe sepsis or septic shock. Mean (SD) age was 59.2 (23.3) years and 49% were female. Medical history included hypertension (29%), diabetes mellitus (26%), stroke (8%), heart failure (6%) and HIV (6%). The most common sources of sepsis were pneumonia (67%) and urinary tract infection (46%). Median, interquartile range (IQR) time from triage to antibiotic administration was 126 (88, 220) minutes and antibiotics were given to 65.7% within three hours. Overall, organisms were sensitive to empirical antibiotics in 69%. Median (IQR) lactate was 5.3 (4.5, 7.5) mmol/L. Most patients (95%) were admitted to the ward; 1% went to the intensive care unit (ICU) and 2% died in the ED. Mean (SD) length of hospital stay was 9.5 (10.3) days. In-hospital mortality was 25% and survival correlated inversely with age (rpb = -0.25; p = 0.006).
CONCLUSION: Despite a lack of EGDT, sepsis treatment patterns were consistent with "best-practice" and mortality was lower than international comparators.

PMID: 24564044 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Share


Apr 182014
 

Comparison of scoring systems and outcome of patients admitted to a liver intensive care unit of a tertiary referral centre with severe variceal bleeding.

Aliment Pharmacol Ther. 2014 Apr 16;

Authors: Al-Freah MA, Gera A, Martini S, McPhail MJ, Devlin J, Harrison PM, Shawcross D, D Abeles R, Taylor NJ, Auzinger G, Bernal W, Heneghan MA, Wendon JA

Abstract
BACKGROUND: Acute variceal haemorrhage (AVH) is associated with significant mortality.
AIMS: To determine outcome and factors associated with hospital mortality (HM) in patients with AVH admitted to intensive care unit (ICU) and to compare outcomes of patients requiring transfer to a tertiary ICU (transfer group, TG) to a local in-patient group (LG).
METHODS: A retrospective study of all adult patients (N = 177) admitted to ICU with AVH from 2000-2008 was performed.
RESULTS: Median age was 48 years (16-80). Male represented 58%. Median MELD score was 16 (6-39), SOFA score was 8 (6-11). HM was higher in patients who had severe liver disease or critical illness measured by MELD, SOFA, APACHE II scores and number of failed organs (NFO), P < 0.05. Patients with day-1 lactate ≥ 2 mmol/L had increased HM (P < 0.001). MELD score performed as well as APACHE II, SOFA and NFO (P < 0.001) in predicting HM (AUROC = 0.84, 0.81, 0.79 and 0.82, respectively P > 0.05 for pair wise comparisons). Re-bleeding was associated with increased HM (56.9% vs. 31.6%, P = 0.002). The TG (n = 124) had less severe liver disease and critical illness and consequently had lower HM than local patients (32% vs. 57%, P = 0.002). TG patients with ≥2 endoscopies prior to transfer had increased 6-week mortality (P = 0.03). Time from bleeding to transfer ≥3 days was associated with re-bleeding (OR = 2.290, P = 0.043).
CONCLUSIONS: MELD score was comparable to ICU prognostic models in predicting mortality. Blood lactate was also predictive of hospital mortality. Delays in referrals and repeated endoscopy were associated with increased re-bleeding and mortality in this group.

PMID: 24738606 [PubMed - as supplied by publisher]

Link to Article at PubMed

Share


Apr 182014
 

Case records of the Massachusetts General Hospital. Case 12-2014. A 59-year-old man with fatigue, abdominal pain, anemia, and abnormal liver function.

N Engl J Med. 2014 Apr 17;370(16):1542-50

Authors: Friedman LS, Simmons LH, Goldman RH, Sohani AR

PMID: 24738672 [PubMed - in process]

Link to Article at PubMed

Share


Apr 182014
 

Transferable vancomycin resistance in a community-associated MRSA lineage.

N Engl J Med. 2014 Apr 17;370(16):1524-31

Authors: Rossi F, Diaz L, Wollam A, Panesso D, Zhou Y, Rincon S, Narechania A, Xing G, Di Gioia TS, Doi A, Tran TT, Reyes J, Munita JM, Carvajal LP, Hernandez-Roldan A, Brandão D, van der Heijden IM, Murray BE, Planet PJ, Weinstock GM, Arias CA

Abstract
We report the case of a patient from Brazil with a bloodstream infection caused by a strain of methicillin-resistant Staphylococcus aureus (MRSA) that was susceptible to vancomycin (designated BR-VSSA) but that acquired the vanA gene cluster during antibiotic therapy and became resistant to vancomycin (designated BR-VRSA). Both strains belong to the sequence type (ST) 8 community-associated genetic lineage that carries the staphylococcal chromosomal cassette mec (SCCmec) type IVa and the S. aureus protein A gene (spa) type t292 and are phylogenetically related to MRSA lineage USA300. A conjugative plasmid of 55,706 bp (pBRZ01) carrying the vanA cluster was identified and readily transferred to other staphylococci. The pBRZ01 plasmid harbors DNA sequences that are typical of the plasmid-associated replication genes rep24 or rep21 described in community-associated MRSA strains from Australia (pWBG745). The presence and dissemination of community-associated MRSA containing vanA could become a serious public health concern.

PMID: 24738669 [PubMed - in process]

Link to Article at PubMed

Share