Primary Small Cell Carcinoma of the Pancreas Presenting With Likely Paraneoplastic Features.

Primary small cell carcinoma of the pancreas (SCCP) is a rare malignancy, and has been associated with paraneoplastic features in only 2 reported cases. We report a rare and fatal case of SCCP with likely paraneoplastic features in a previously well 67-year-old woman presenting with abdominal pain. She was found to have abnormal biochemical markers (hyperkalaemia and hyponatraemia) with a normal abdominal CT. Emergency laparotomy identified a mass at the head of the pancreas and liver metastases, she died soon after, and diagnosis was confirmed post-mortem.

Improving door-to-needle times for patients presenting with ST-elevation myocardial infarction at a rural district general hospital.

Acute coronary syndrome is a common condition with a major global impact on healthcare resources and expenditure. International guidelines are clear in specifying that patients with acute ST-elevation myocardial infarction (STEMI) should receive urgent coronary reperfusion with either primary percutaneous coronary intervention (PCI) or thrombolysis. Although PCI is the gold standard in the treatment of STEMI, this is not always achievable in a rural hospital with no cardiac catheterization service. Consequently, local recommendations on STEMI management exist to promote timely administration of thrombolysis within 30 minutes of patient arrival. However, translating updated clinical policy into practice is a challenging and complex task that requires a multi-faceted approach with sustained engagement from local stakeholders. Whilst working at a district general hospital in New Zealand, we noted a high incidence of patients presenting with STEMI receiving thrombolytic therapy outside the recommended 30 minutes door-to-needle time. Although final treatment was often only delayed by 5-10 minutes, we were concerned by the seemingly inconsistent management of these patients, often leading to unnecessary delays in the initiation of rapid reperfusion therapy. We therefore championed a newly updated clinical guideline and promoted an early STEMI recognition and treatment algorithm in our hospital to raise awareness amongst staff and improve door-to-needle times. We introduced a number of simple low-cost interventions that included educational sessions for junior doctors and cardiac nursing staff, as well as posters and training on the use of a remote electronic ECG interpretation system to streamline out-of-hours management. Overall, we found there to a be a steady improvement in door-to-needle times at our hospital, with 74% of patients receiving appropriate care within 30 minutes, compared to 43% prior to our interventions. This also translated to better patient outcomes. This project forms part of an ongoing process to instigate quality improvements in the management of STEMI within rural institutions. Whilst we have demonstrated improved utilisation of a local STEMI guideline and streamlining of out-of-hours services, the key challenge remains to ensure that momentum of this project continues and forms a platform for sustainable clinical improvement in the long term.

Improving the management of sepsis in a district general hospital by implementing the 'Sepsis Six' recommendations.

Sepsis is a common condition with a major global impact on healthcare resources and expenditure. The Surviving Sepsis Campaign has been vigorous in promoting internationally recognised pathways to improve the management of septic patients and decrease mortality. However, translating recommendations into practice is a challenging and complex task that requires a multi-faceted approach with sustained engagement from local stakeholders. Whilst working at a district general hospital in New Zealand, we were concerned by the seemingly inconsistent management of septic patients, often leading to long delays in the initiation of life-saving measures such as antibiotic, fluid, and oxygen administration. In our hospital there were no clear systems, protocols or guidelines in place for identifying and managing septic patients. We therefore launched the Sepsis Six resuscitation bundle of care in our hospital in an attempt to raise awareness amongst staff and improve the management of septic patients. We introduced a number of simple low-cost interventions that included educational sessions for junior doctors and nursing staff, as well as posters and modifications to phlebotomy trolleys that acted as visual reminders to implement the Sepsis Six bundle. Overall, we found there to a be a steady improvement in the delivery of the Sepsis Six bundle in septic patients with 63% of patients receiving appropriate care within one hour, compared to 29% prior to our interventions. However this did not translate to an improvement in patient mortality. This project forms part of an on going process to instigate a fundamental culture change among local healthcare professionals regarding the management of sepsis. Whilst we have demonstrated improved implementation of the Sepsis Six bundle, the key challenge remains to ensure that momentum of this project continues and forms a platform for sustainable clinical improvement in the long term.

Hypokalaemia: Improving the investigation, management and therapeutic monitoring of hypokalaemic medical inpatients at a district general hospital.

Hypokalaemia is prevalent in 20% of hospitalised patients. Furthermore, inadequate management of hypokalemia was identified in 24% of these patients. Associated with significant patient morbidity and mortality, the identification, investigation, and treatment of hypokalaemia was identified as an area for improvement in the management of medical inpatients. The project aims to measure the assessment, management, and therapeutic monitoring of medical inpatients with hypokalaemia in a district general hospital. All medical inpatients over a one week period who met the criteria for hypokalaemia (serum potassium <3.5 mmol/L on standard biochemical sample) were included in the audit. Patient's notes were located and evaluated to identify if they had mild, moderate, or severe hypokalaemia. Further data on ECG requests, repeat U&Es, serum magnesium analysis, treatment prescribed, and medication review dates was collated. A re-audit was completed after the introduction of a set of interventions which included a hypokalaemia treatment algorithm. Pre-intervention analysis of all medical inpatients, who met our inclusion criteria for hypokalaemia, identified 32 patients. 25 of these patients met the criteria for mild hypokalaemia (3.1-3.4 mmol/L) and 7 met the criteria for moderate hypokalaemia (2.5-3.0 mmol/L). Only 7/32 (22 %) patients were receiving adequate treatment based on trust guidelines. Post intervention results showed marked improvement in the management of patients with hypokalaemia. A total of 30 patients were identified in this post-intervention group. There were 16/30 patients who qualified as mild hypokalaemia (3.1-3.4 mmol/L) and 14/30 with moderate hypokalaemia (2.5-3.0 mmol/L). 19/30 (63%) patients in the post-intervention group were correctly prescribed appropriate medication doses consistent with the treatment algorithm. Following the initial success of the project, analysis at 3 months showed a positive trend for sustained improvement when compared to the pre-intervention results.