Antecedents to hospital deaths.

BACKGROUND: Recent studies have suggested there are a large number of potentially preventable deaths in Australian hospitals. AIM: This study aimed to document antecedent factors in hospital deaths in an attempt to identify potentially preventative factors. METHODS: The study was conducted at three separate acute hospitals. Demographics of all deaths were recorded over a 6-month period as well as antecedent factors present within 0-8 and 8-48 h of all deaths including vital sign abnormalities, cardiorespiratory arrests and admission to intensive care. Separate analysis was performed on 'not for resuscitation' deaths. RESULTS: There were a total of 778 deaths, of which 549 (71%) were 'not for resuscitation'. There were 171 (22%) deaths preceded by arrest and 160 (21%) preceded by admission to intensive care. Of the remaining deaths, 30% had severely abnormal physiological abnormalities documented. This incidence was 50% in the non-do not resuscitate (DNR) subgroup. Concern about the patient's condition was expressed in the patient's notes by attending nursing staff and junior medical staff in approximately one-third of non-DNR deaths. Hypotension (30%) and tachypnoea (17%) were the most common antecedents in the non-DNR deaths. CONCLUSION: There is a high incidence of serious vital sign abnormalities in the period before potentially preventable hospital deaths. These antecedents may identify patients who would benefit from earlier intervention.

Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team.

OBJECTIVES: To evaluate the effectiveness of a medical emergency team (MET) in reducing the rates of selected adverse events. DESIGN: Cohort comparison study after casemix adjustment. PATIENTS AND SETTING: All adult (> or = 14 years) patients admitted to three Australian public hospitals from 8 July to 31 December 1996. INTERVENTION STUDIED: At Hospital 1, a medical emergency team (MET) could be called for abnormal physiological parameters or staff concern. Hospitals 2 and 3 had conventional cardiac arrest teams. MAIN OUTCOME MEASURES: Casemix-adjusted rates of cardiac arrest, unanticipated admission to intensive care unit (ICU), death, and the subgroup of deaths where there was no pre-existing "do not resuscitate" (DNR) order documented. RESULTS: There were 1510 adverse events identified among 50 942 admissions. The rate of unanticipated ICU admissions was less at the intervention hospital in total (casemix-adjusted odds ratios: Hospital 1, 1.00; Hospital 2, 1.59 [95% CI, 1.24-2.04]; Hospital 3, 1.73 [95% CI, 1.37-2.16]). There was no significant difference in the rates of cardiac arrest or total deaths between the three hospitals. However, one of the hospitals with a conventional cardiac arrest team had a higher death rate among patients without a DNR order. CONCLUSIONS: The MET hospital had fewer unanticipated ICU/HDU admissions, with no increase in in-hospital arrest rate or total death rate. The non-DNR deaths were lower compared with one of the other hospitals; however, we did not adjust for DNR practices. We suggest that the MET concept is worthy of further study.

Problems following discharge after intensive care.

Intensive care units (ICUs) are now present in most acute care hospitals. While long-term studies on patients admitted to these units have been performed to identify mortality, functional outcome and quality of life, there is little information on the recovery period in the weeks immediately following discharge. The aim of this study was to identify and describe the sequelae found in patients at 3 months after leaving the ICU. The study was conducted over a 6-month period during 1991, in a university teaching hospital in Sydney, Australia. 54 patients with a length stay (LOS) of greater than 48 hours in the ICU were included. Each patient was interviewed in an outpatient clinic attached to the ICU. Information collected included pre-admission details, reason for admission, treatments provided and complications encountered. General health state, social and employment details, functional status, referral patterns since discharge and recollection of ICU stay were studied. The major findings indicated that many of the patients interviewed were returning towards near normal general health, but were suffering mild to moderate physical and psychosocial sequelae. In the majority of cases the problems were not incapacitating. The predominant complaints were minor to severe pain, sleeping difficulties, tiredness and breathlessness. Financial problems were reported by a small number of patients. Depression, irritability or a feeling of loneliness were present in over one-third of the group. More than half the patients required referral for further assessment. 34% of patients had no recollection of their ICU stay. 16 patients (29.6%) reported unpleasant memories including nightmares and hallucinations.(ABSTRACT TRUNCATED AT 250 WORDS)

Do nurses know when to summon emergency assistance?

At Liverpool Hospital in 1989, mortality from cardiopulmonary arrest was 71% in the general wards, and 64% in the Emergency department. In an attempt to identify and treat seriously ill patients before they progressed to cardiac arrest, a medical emergency team (MET) was established. The MET replaced the existing cardiac arrest team and comprised a nurse from the intensive care unit (ICU), a resuscitation registrar (an anaesthetics trainee), a medical registrar and a senior registrar from the ICU. The resuscitation registrar was the team leader. The calling criteria for the MET were based on predetermined physiological variables, abnormal laboratory results, and specific conditions or if nursing or medical staff were concerned by the patient's condition. A study was conducted 2 years following implementation of the MET system, to determine registered nurses' (RNs) opinions, knowledge and use of the system. A questionnaire distributed to 141 nurses rostered on the chosen study date revealed a positive attitude the MET, although there was a low awareness regarding the availability of the MET information booklet. 53% of nurses had called the MET in the last 3 months; all would call the team again in the same circumstances. The correct response in three of four hypothetical situations presented was to call the MET. The number of correct responses varied between scenarios from 17-73%. Hypotension did not appear to alert nurses to summon emergency assistance. Some nurses, despite the presence of severe deterioration and patient distress, called the resident rather than the MET.(ABSTRACT TRUNCATED AT 250 WORDS)

Severe heat stroke in an experienced athlete.

A 28-year-old experienced athlete suffered severe heat stroke after running competitively in hot, humid conditions. He developed disseminated rhabdomyolysis and acute renal failure. His course was complicated by multiple system organ failure and bismuth iodide (BIPP) toxicity. After almost five months in intensive care he recovered sufficiently to be transferred to the ward and subsequently to a rehabilitation hospital and was eventually able to return to work. Heat stroke can be prevented and this case provides several lessons for the running fraternity and the medical profession.

Density and the commitment of apical meristems to clonal growth and reproduction in Hieracium pilosella.

We examined responses to population density in the commitment of apical meristems to reproduction and clonal growth in a rosette-forming, stoloniferous herb (Hieracium pilosella). Despite close physiological coupling between the evocation of the terminal inflorescence bud and the development of one or more axillary buds into stolons, the allocation of meristems was extremely plastic.Genets at the higher sowing densities showed density-dependent mortality consistent with self-thinning along a-3/2 trajectory. The probability of inflorescence evocation and associated stolon development was negatively dependent on surviving density. The proportinal distribution of primary stolons amongst genets became strikingly more unequal (expressed as the Gini coefficient) with increasing density. Clonal growth was resolved into the number of primary stolons per stoloniferous genet and the extent of stolon branching (i.e. number of apices per primary stolon); both showed strongly negative density-dependence. Reproduction, expressed as the mean number of flowering capitula per stoloniferous genet, declined 15-fold with increasing density; although theoretically expected to be unity, greater values resulted from capitulum production by attached secondary rosettes and lower values reflected the increasing abortion rate of inflorescence buds with increasing density.Both the total number of apices produced per unit area and the corresponding number of reproductive apices were maximal at intermediate surviving densities (700-1,000 m-2). The balance between reproductive and clonal growth may be expressed as the probability of an apical meristem producing a capitulum, that also peaked sharply at intermediate density. This finding does not conform with linear models that predict a shift from vegetative growth to sexual reproduction with increasing population density.

Pseudomonas botryomycosis.

A patient had cutaneous botryomycosis due to Pseudomonas aeruginosa. The diagnosis of botryomycosis was based on the clinical manifestations, results of bacterial culture, and demonstraction of the Gram-negative organisms by tissue Gram stain of the granules in the dermis and subcutaneous fat. Numerous laboratory tests, including tissue immunofluorescence and special studies with the patient's lymphocytes, failed to demonstrate an abnormality that might help to explain the pathogenesis of the granular tissue reaction in this patient.

Nevus sebaceous and syringocystadenoma papilliferum.

A 52-year-old patient was admitted to the hosptial for evaluation of hypertension. He had two skin lesions, one on the forehead and one in the postauricular area, which had been present since birth. The forehead lesion was a nevus sebaceous and the postauricular lesion was a syringocystadenoma papilliferum. Except for a few patients with widespread nevus sebaceous and syringocystadenoma papilliferum associated with neurologic abnormalities, most of the previously reported patients with these nevi have had solitary lesions of one or the other. An association of nevus sebaceous and syringocystadenoma papilliferum in the same lesion is not uncommon. Despite bleeding and crusting in one of the lesions and despite informing the patient that a malignant neoplasm may develop in these nevi, he refused excision of either of the lesions.

Acute febrile neutrophilic dermatosis (Sweet syndrome).

We describe the third reported case of acute febrile neutrophilic dermatosis (Sweet syndrome) in the United States. In the majority of reported cases, the patients were female. However, in our case and in the two cases reported previously in the United States, the patients were male. In two of these three male patients, a malignant neoplasm has been found, possibly as a coincidence.