Monitor, the Care Quality Commission and the Future Hospital: the medical director's tale.

The Future Hospital Commission suggested a number of ways in which hospital and other services should evolve to meet the changing medical needs of the communities they serve. The Health and Social Care Act (and the requirement that places on the regulator, Monitor) focuses on the need for competition and tendering of services to drive up standards. The Care Quality Commission on the other hand, partly in response to well publicised shortcomings, has changed its inspection programme to focus on quality, and the centrality of well led co-ordinated patient care. This article describes the author's recent experience of a CQC inspection to his own hospital and some of the lessons learned. It is perhaps possible to align the goals of the CQC and their inspection teams with those of the organisation, to improve patient care in line with the Future Hospital recommendations.

Liver albumin synthesis in sepsis in the rat: influence of parenteral nutrition, glutamine and growth hormone.

The effect of sepsis on liver synthesis of albumin remains controversial, with studies in man suggesting that synthesis increases, whereas in animals increased, decreased and unaltered synthesis have been reported. To reconcile these conflicting data, total and relative albumin synthesis was measured in rats 24 h after caecal ligation and puncture (CLP) by immunoprecipitation of albumin following a flooding dose of L-[4-3H]phenylalanine. Following CLP, animals were starved for 18 h and then received intravenous infusions of saline or parenteral nutrition (PN) with or without glutamine for 6 h. In animals receiving PN, parenteral injections of growth hormone (GH) or saline vehicle were also administered. Fractional rate of liver total protein synthesis was elevated and total albumin synthesis rate was reduced in all CLP groups when compared with non-operated animals. Total albumin synthesis was also lower in all animals receiving PN than those receiving saline alone, although these differences did not attain statistical significance, except for the group receiving PN+GH. Relative albumin synthesis was also reduced after CLP, and was significantly lower in animals receiving PN than in those receiving saline alone. These findings suggest that in sepsis hepatic protein synthesis is reprioritized away from the production of albumin towards the production of acute-phase proteins and that this change is not influenced by the provision of nutritional support, glutamine or the administration of GH.

Persistent neuromuscular and neurophysiologic abnormalities in long-term survivors of prolonged critical illness.

OBJECTIVE: To establish the prevalence, clinical characteristics, and electrophysiologic features of residual neuromuscular dysfunction after prolonged critical illness. DESIGN: Prospective follow-up study of survivors of prolonged critical illness. SETTING: A university hospital and two district general hospitals in the UK. PATIENTS: The study occurred for a period of 5 yrs. All patients during that time who were in the intensive care unit for >28 days were entered in the study. MEASUREMENTS AND MAIN RESULTS: At follow-up, length of intensive care unit and hospital stay, duration of mechanical ventilation and admission Acute Physiology and Chronic Health Evaluation II score were recorded from the case notes. A clinical history was obtained, a Barthel Index disability score was calculated, and a full neurologic examination was performed. Nerve conduction studies, needle electromyography, single-fiber electromyography and thermal thresholds were performed. A total of 195 patients were identified. There were 86 survivors, of whom 47 could be contacted and 22 consented to be studied. The median time from intensive care unit discharge to follow-up was 43 months (range, 12-57 months). All gave a clear history of severe weakness and functional impairment after hospital discharge and, in all, recovery was prolonged. Motor or sensory deficits were present on clinical examination in 59% of the patients studied. Common peroneal nerve palsy was present in two patients. A total of 21 of 22 (95%) patients had electromyographic evidence of chronic partial denervation at follow-up, findings indicative of a preceding axonal neuropathy. The single-fiber electromyographic studies were also consistent with a preceding motor neuropathy. CONCLUSION: Severe weakness requiring prolonged rehabilitation and abnormal clinical neurologic findings are extremely common in survivors of protracted critical illness. Neurophysiologic evidence of chronic partial denervation of muscle consistent with previous critical illness polyneuropathy is almost invariable and can be found up to 5 yrs after intensive care unit discharge in >90% of these long-stay patients. Evidence of myopathy is unusual. These findings have important implications for the management and rehabilitation of intensive care survivors.

Influence of starvation, surgery, and sepsis on cardiac protein synthesis in rats: effects of parenteral nutrition, glutamine, and growth hormone.

The effect of sepsis on the rate of protein synthesis in the heart is poorly described. We have investigated changes in protein synthesis in the ventricles of the heart over time after cecal ligation and puncture (CLP) in rats in comparison with sham-operated and unoperated animals (ad libitum). All operated animals were starved from the time of surgery to the time of sacrifice. When operated animals were compared with ad libitum animals, ventricular weight and ventricular protein, and DNA and RNA contents were unchanged at 24 h, but were invariably reduced at 72 and 96 h. Fractional rate of protein synthesis (FSR), RNA activity, and cellular efficiency were reduced at 24 h and further reduced at 72 and 96 h. There were no differences, however, between septic and sham-operated animals. Eighteen hours after CLP, additional groups of rats were infused intravenously with 0.9% sodium chloride, parenteral nutrition (PN), or PN with glutamine, and were given a single dose of 400 microg recombinant human growth hormone (rhGH) or an equal volume of 0.9% sodium chloride. FSR was higher in animals given PN when compared with those given 0.9% sodium chloride only, and did not differ from FSR measured in unoperated animals. There was no additional benefit from the acute administration of either glutamine-enriched PN or rhGH. These results indicate that ventricular protein synthesis is markedly reduced by surgery and starvation, but that superimposed sepsis does not further influence these changes. PN can prevent the fall in cardiac protein synthesis associated with starvation, surgery, and sepsis, but neither glutamine nor rhGH produced any additional benefit.

Effect of growth hormone on muscle and liver protein synthesis in septic rats receiving glutamine-enriched parenteral nutrition.

OBJECTIVE: Administration of recombinant human growth hormone (rhGH) to critically ill adults in an attempt to attenuate catabolism was associated with increased morbidity and mortality. Possible explanations included inhibition of glutamine release from skeletal muscle and consequent restriction of splanchnic glutamine supply. In this study, we examined the effects of rhGH on plasma glutamine levels and on muscle and liver glutamine concentrations and protein synthesis rates in sepsis. We investigated the possibility that administration of supplemental glutamine might ameliorate any adverse effects of rhGH. DESIGN: Prospective study in rats rendered septic by cecal ligation and puncture. SETTING: University hospital laboratory. SUBJECTS: A total of 78 male Wistar rats in six groups. INTERVENTIONS: Animals received 6-hr tail vein infusions, commencing 18 hrs after cecal ligation and puncture, of either (a) 0.9% sodium chloride, (b) a standard parenteral nutrition (PN) solution without glutamine, or (c) an isocaloric, isonitrogenous PN solution with glutamine. PN groups received 400 microg rhGH or equivolume 0.9% sodium chloride vehicle in a divided subcutaneous and intravenous dose at PN commencement. Sacrifice was at the end of the infusion period. A further group was unoperated and uninfused and killed at 24 hrs as baseline controls. MEASUREMENTS AND MAIN RESULTS: Glutamine concentrations were measured by fluorometry. Protein synthesis in muscle and liver was measured by a "flooding-dose" technique employing L-[4-H]phenylalanine. Plasma glutamine was increased after cecal ligation and puncture except in the saline and glutamine with rhGH animals. Muscle glutamine was reduced after cecal ligation and puncture and was significantly lower in animals receiving standard PN with rhGH vs. saline alone. Liver glutamine was increased in animals receiving saline and those receiving standard PN with rhGH. PN, with or without glutamine, increased muscle protein synthesis, and the administration of rhGH tended to further increase this effect. Neither PN, glutamine, nor rhGH had an effect on the increased liver protein synthesis characteristic of sepsis. CONCLUSIONS: In sepsis, increased muscle protein synthesis with PN and rhGH administration is not associated with increased muscle glutamine levels. Administration of rhGH does not result in reduced liver glutamine levels or rates of hepatic protein synthesis. PN containing glutamine was no more efficacious than standard PN at increasing muscle protein synthesis.