Certification of donor apheresis nurses: keys to develop an effective training program.

Within Sanquin Blood Supply, a training program to train apheresis nurses was developed. The parts of the work for which qualification should be necessary was analysed. Based on this analysis, a modular program with theoretical and practical information and knowledge was developed. The modular program consists of two sections: a theoretical and technical / practical. The theoretical section consists of by the project group identified themes including basic hematology (e.g. the characteristics, kinetics, physiology and function of blood cells), basic apheresis physiology, indications for apheresis procedures, criteria for donors apheresis, difficulties and risks of procedures as well as the actions to be taken in case of side effects, and introduction to the apheresis machine available, including the mechanism of the machine. The program for the technical / practical section consists of machine and procedure knowledge (in theory and practise) and troubleshooting. To conclude each individual module, tests in theory and capability to perform procedures are taken. Each trainee needs to demonstrate to have sufficient insight and skill to master all the relevant critical features of the work. Also a text-book for the trainee was written. This educational program provides an approach to educate and test apheresis donor nurses. The combination of theoretical and practical components and monitoring of the progression are an important basis.

Use of water jet resection in renal surgery: early clinical experiences.

OBJECTIVE: Various surgical techniques have been developed to reduce the risk of bleeding during dissection of renal tissue. Water jet technology has been designed for a gentle transection of parenchymal organs. We report about first experiences with a new water jet resection device in kidney surgery. METHODS: 7 patients underwent open surgery because of renal cell carcinoma or nephrolithiasis. In tumor patients a partial nephrectomy, in 1 stone patient a nephrolithotomy, and in the other 1 a lower pole resection were performed. RESULTS: By means of water jet resection tissue was dissected effectively avoiding damage to the vascular structures, which were then ligated selectively. Resection time was between 14 and 30 min with a minimal intraoperative blood loss. No significant problem was seen postoperatively. CONCLUSIONS: The results demonstrate that water jet technology is an applicable tool for transection of renal parenchyma. It has been shown to reduce the risk of blood loss significantly compared to other techniques.

Comparison of severity of illness indicators in an intensive care unit.

Meaningful comparison of patient outcomes requires an assessment of the severity of illness for the patients being compared. The more severe the underlying illness, the worse the expected outcome. We studied several severity of illness indicators derived from different methodologies in a medical intensive care unit. We compared the Acute Physiologic and Chronic Health Evaluation II, the accepted benchmark indicator for intensive care units, with one complex indicator, Computerized Severity Score, and three simpler indicators, Comorbidity, McCabe-Jackson, and American Society of Anesthesiologists. We found that all correlated well with a comorbidity index. We conclude that the Acute Physiologic and Chronic Health Evaluation II, the Computerized Severity Score, and the McCabe-Jackson scoring systems appear to be comparable predictors of comorbidity in a medical intensive care unit. Selection of a severity indicator will depend on the resources available and the intended uses.

Number of comorbidities as a predictor of nosocomial infection acquisition.

Infection control programs are primarily oriented toward chronicling the incidence of nosocomial infections (NI). Intervention programs oriented toward preventing infection would be facilitated by identifying patients at greatest risk of NI acquisition. We studied the number of comorbidities as a risk predictor for NIs in patients admitted to the medical intensive care unit (ICU) for three or more days. In 148 patients, we found by regression analysis that the number of comorbidities varied directly with the development of nosocomial infections, as well as with the appearance of new complications and length of ICU stay. Diagnosis-related groups did not adequately account for the variance in comorbidities observed.

Myeloradiculopathy associated with wasp sting.

A 12-year-old girl developed a reversible myeloradiculopathy 1 week after a wasp sting. Delayed neurologic hypersensitivity reactions to Hymenopteran stings occur primarily in adults. Reactions involving both the peripheral and central nervous systems are extremely rare and have never been reported in a child. The mechanisms underlying this uncommon reaction may be related to age-dependent differences in immunologic responses.

Nemaline myopathy associated with hypertrophic cardiomyopathy.

Nemaline myopathy is not usually considered to involve cardiac muscle and rarely is associated with nocturnal hypoventilation. We report a boy, 5 1/2 years of age, with nemaline myopathy who presented with respiratory failure. Echocardiography demonstrated the septum to left ventricular posterior wall ratio to be increased which is consistent with a hypertrophic cardiomyopathy. Because of nocturnal hypoventilation, tracheostomy was placed for ventilatory assistance. A process involving both muscle and nervous tissue may underlie this congenital myopathy; routine cardiac and pulmonary function evaluations may be indicated in these patients.

Use and abuse of blood cultures: program to limit use.

Many health care providers order an unnecessary number of blood cultures. We studied the ordering habits in our medical intensive care unit and recommended a protocol for appropriate ordering. Implementation of the protocol resulted in a significant reduction in the number of episodes of suspected sepsis, from 39% of patient discharges during the baseline period to 16% during the study period (p = 0.008). The mean number of blood cultures decreased significantly from 1.2 per patient discharge to 0.3 (p = 0.003). The number of episodes when more than four blood cultures were ordered decreased from 7 to 0, resulting in an annual cost savings estimated at $8025. The net benefit was reversed, however, when the protocol ceased to be actively implemented. We concluded that the appropriate ordering of blood cultures can be effected by establishing a protocol that is actively and continuously implemented.

Starting a plasmapheresis program with hollow-fiber filtration.

In a routine donor center, a program of hollow-fiber filtration can be instituted. With the Organon Teknika PLASMAPUR system the collection of 600 ml plasma was completed within 50 min in 76% of the procedures. Changing the tubing set took 12-15 min. From the plasma a frozen cryoprecipitate is made with a recovery of 59%. After pooling, lyophilization and heat treatment, the recovery is 42%.

Nosocomial infections and hospital deaths. A case-control study.

In an earlier study, nosocomial infections were reported to occur in one third of patients who died in the hospital. Lower respiratory tract infections appeared to be causally related to death, whereas urinary tract infections were not. A case-control study was therefore conducted to begin to explore epidemiologically these causal suppositions. By definition, all 100 patients in the case group died in the hospital and all 100 patients in the control group survived hospitalization. A patient in the control group was matched to a patient in the case group for age, sex, service, primary discharge diagnosis, and severity of primary diagnosis. Secondary discharge diagnoses were comparable in both groups. Nosocomial infections were present in 33 percent of patients in the case group and 13 percent of patients in the control group (p less than 0.001). Lower respiratory tract nosocomial infections occurred in 18 percent of patients in the case group and 4 percent of patients in the control group (p less than 0.005). Urinary tract nosocomial infections occurred in 6 percent of patients in the case group and 8 percent of patients in the control group (p = NS). Presence of a terminal prognosis on admission was found more often in case group patients than in control group patients (76 percent versus 11 percent, p less than 0.001). Nosocomial infections appeared to favor a fatal outcome only in those whose condition was not terminal on admission (p less than 0.05). In those whose condition was terminal on admission, the incidence of infection was equal in those who survived and in those who died. In conclusion, in these two groups well matched by many criteria, differences in prognosis on admission probably accounted for the major differences in survival. Nosocomial infections may affect outcome in those whose condition is not terminal on admission.

Surveillance for nosocomial infections: can the sources of data be reduced?

With the goal of achieving economy in infection control surveillance we tested the relative efficiency of the various surveillance sources for detecting nosocomial infections (NIs). We reviewed the initial and final surveillance sources of 415 NIs at Hackensack Hospital during an 11-month period; cultures were taken on most of the patients with NIs. Positive microbiology cultures were the initial sources in 64.8% of NIs and secondary sources in 23.6%. Chart review of patients with positive cultures added another 2.9%. Therefore, 91.3% of NIs could have been detected by positive culture reports. The remainder were discoverable by notification from nurses, or by studying admission cards or temperature rounds. Although the NIs missed by lack of a positive culture report often were significant infections, these alternate methods of surveillance did not help to detect any clusters of infections that could be traced to a particular source among the staff or the environment.

Deaths from nosocomial infections: experience in a university hospital and a community hospital.

To assess the importance of nosocomial infections as a contributory cause of death in patients who die in the hospital, we studied the hospital course of 100 consecutive patients who died at Columbia-Presbyterian Medical Center and 100 consecutive patients who died at Hackensack Hospital. The epidemiologic patterns of infection were similar although the institutions provide care for different types of patients. There were 88 nosocomial infections in 63 patients. When the nosocomial infection was causally related or contributed to death, infection of the lower respiratory tract was predominant in 31 of 52 (60 per cent) instances. When the nosocomial infection was unrelated to death, urinary tract infection was predominant in 13 of 36 (36 per cent) infections. Among those who died with nosocomial infection, 42 of 63 (67 per cent) patients were terminal on admission and were typically in their 60's with metastatic carcinoma. The 21 patients who were not terminal on admission were typically in their late 70's and had complications of arteriosclerotic cardiovascular disease. Pneumonia was the most frequent nosocomial infection related to death. There is need to devise a pneumonia prevention program that identifies those at high risk and reduces the chance of aspiration of pharyngeal secretions and spread of virulent bacteria from person to person.