Enhancing outcomes: guidelines, standards, and protocols.

Guidelines, protocols, and standards have gained attention as clinical tools designed to enhance clinical decision-making and practice. Yet, evidence has emerged that clinicians are having difficulty integrating new knowledge presented by these tools into practice. This article explores the benefits and barriers to using guidelines and protocols, probes the issues of producing these tools, and examines processes that are critical to constructing valid tools. The key functions important in successful development and implementation of guidelines and protocols are presented, as well as the direction these clinical adjuncts will take in the future.

The renaissance begins with you ... the search is on for best practices.

A new spirit of innovation is arising in health care. Just as the historical renaissance opened new frontiers of European art, architecture, science, and literature, we have the opportunity to release a new wave of innovation that will revolutionize healthcare delivery. The means are near at hand. Never before has our knowledge been so deep, technology so powerful, or communications so fast and wide. Yet, like medieval scholars, isolated in our monasteries, we have so far had limited effect in positively changing the system. Real change begins today--as soon as we begin talking to one another, comparing our experiences, sharing our problems, devising solutions, and imagining the future together.

Asthma: a provincial study.

To identify factors contributing to increased mortality and morbidity we prospectively evaluated 200 consecutive adult (greater than 17 years) asthmatic presentations (105 patients) referred to Gisborne Hospital over a 28 month period between 1985 and 1987 using a modified protocol adapted from previous national studies. In the moderate asthmatic group (113 presentations, 56%), 6% failed to use beta agonists prior to admission and 43% were not on regular steroid inhaler therapy. No patient had a crisis plan although 45 (22.5%) had received oral steroid therapy before admission. Poor drug compliance was twice as common in the Maori. Fifty-eight percent of patients were on regular long term oral theophylline whereas 48 (43%) patients with moderate and severe asthma were not on corticosteroid inhalers. We conclude that patient education and more liberal use of steroid inhalers have the greatest potential for improving morbidity and mortality.

Clinical manifestations of hypomagnesemia.

We observed prospectively 20 consecutive patients with severe hypomagnesemia (serum Mg 0.01 to 1.2 mg/dl [0.01 to 0.5 mmol/L], mean 0.8 mg/dl [0.33 mmol/L]) before and after correction with parenteral magnesium sulfate. Only three patients, all with hypocalcemia, had tremor and muscle twitching and none showed tetany, a positive Trousseau's test, arrhythmias, or ECG abnormalities. Moreover, review of the literature on hypomagnesemia did not justify attributing these clinical symptoms to hypomagnesemia. In a follow-up study of 111 consecutive serum samples from hypocalcemic patients, 36 (32%) indicated hypomagnesemia (serum Mg no greater than 1.5 mg/dl [0.6 mmol/L]); however, hypomagnesemia had been unsuspected in all but two patients. We conclude that hypomagnesemia rarely shows specific signs or symptoms; its diagnosis depends on a high index of suspicion in patients with hypokalemia, especially after its correction, and in patients with unexplained hypocalcemia.

Maintenance of basal insulin secretion in severe non-insulin-dependent diabetes.

It has been postulated that glucose regulation is secondary to maintenance of normal basal insulin secretion. Serum glucose, insulin, and C-peptide levels were measured at fasting in 209 consecutive non-insulin-dependent diabetic patients and after glucose stimulation in 193 patients. The basal serum insulin C-peptide levels were not significantly different in control subjects (mean 22 +/- 8.8 microU/ml) and in patients with varying severity of diabetes (mean 24 +/- 9.6 microU/ml) except in the most severely diabetic group [fasting serum glucose greater than 350 mg/dl (19.4 mmol/L), mean 19 +/- 7 microU/ml]. In 39 patients who developed ketonuria without acidosis during follow-up, the mean basal serum insulin was 22 microU/ml during the episode of ketonuria, 21 microU/ml during the glucose tolerance test, and 25 microU/ml after glucose stimulation (statistically nonsignificant differences). Our data suggest that hyperglycemia compensates for beta-cell impairment so that basal insulin secretion usually stays above the threshold for ketoacidosis unless there is marked beta-cell impairment. Patients who fail to increase insulin in response to nutrient challenge are at risk of developing ketosis.

Skin clues in the diagnosis of life-threatening infections.

Skin lesions, an important clue to the cause of septicemia, result from five main processes: (1) disseminated intravascular coagulation and coagulopathy; (2) direct vascular invasion and occlusion by bacteria or fungi; (3) immune vasculitis and immune complex formation; (4) emboli from endocarditis; and (5) vascular effects of toxins. Disseminated intravascular coagulation probably plays only a minor role in pathogenesis. Vascular invasion by bacteria may result in a severe inflammatory reaction, as in meningococcemia, or in a minimal reaction, as in ecthyma gangrenosum. Gram-stained smears of scrapings from the base of skin lesions--a frequently neglected procedure--is an important diagnostic adjunct. Skin biopsies are particularly important in the diagnosis of Rocky Mountain spotted fever and infections caused by Candida.

Acquired immune deficiency syndrome in the Middle East from imported blood.

In Saudi Arabia, a native patient with no known risk factors for the acquired immune deficiency syndrome (AIDS) developed both clinical and laboratory evidence of AIDS 2 years after receiving transfusion of 11 units of blood obtained from a commercial distributor in the United States. This case suggests that a history of transfusions of blood components imported from areas where AIDS is prevalent should be elicited from patients in the Middle East with symptoms and physical findings suggesting AIDS.

Diabetes mellitus in chronic active hepatitis and cirrhosis.

One hundred consecutive patients with nonautoimmune chronic active hepatitis (51% HBsAg-positive), 50 patients with cirrhosis (38% HBsAg-positive), 25 patients with chronic persistent hepatitis, and 118 patients with hepatoma who were seen at this hospital were reviewed to determine the prevalence and characteristics of glucose intolerance and diabetes in these conditions. Diabetes (fasting serum glucose greater than 7.8 mmol/L, 140 mg/dl on two separate occasions) was present in 8% of patients with chronic persistent hepatitis and mild chronic active hepatitis, 44% of patients with severe chronic active hepatitis, 40% of patients with cirrhosis, and 15% of patients with hepatoma, compared with 7% of all other patients aged 35 yr or over, undergoing liver biopsy. Compared with this high prevalence of diabetes in liver disease, only 3% of diabetic patients referred to the hospital diabetic clinic had chronic hepatitis or cirrhosis. Glucose tolerance was similar in chronic active hepatitis and cirrhosis and was characterized initially by basal hyperinsulinemia, normal basal glucose levels but elevated serum glucose following glucose loading, and evidence of insulin resistance. We suggest that the high prevalence of diabetes in chronic active hepatitis and cirrhosis in Saudi Arabia is due to the insulin resistance of chronic liver disease acting over many years in a population with a high genetic predisposition to diabetes.

Hyperventilation in tricyclic antidepressant poisoning.

A patient with severe tricyclic antidepressant poisoning who showed recurrent ventricular fibrillation and wide QRS complexes on the ECG, failed to respond to intravenous physostigmine and lidocaine. Deliberate artificial hyperventilation was immediately effective in preventing further arrhythmia and in decreasing the width of the QRS complexes. Hyperventilation, a neglected treatment, may be immediately effective in the treatment of severe tricyclic antidepressant poisoning.

The syndrome of pneumococcemia, disseminated intravascular coagulation and asplenia.

A 58-year-old man who survived an episode of fulminant pneumococcal septicemia with disseminated intravascular coagulation had undergone splenectomy 23 years previously. In the literature there are 25 reported cases of fulminant septicemia and disseminated intravascular coagulation associated with asplenia in adults (excluding cases in which corticosteroid or immunosuppressive therapy was given). The pneumococcus was responsible for all of these cases as well. The mortality in this series was more than 90%, and death occurred within 24 hours of presentation at hospital in almost 70% of the fatal cases and was associated with high-density bacteremia and adrenal hemorrhage. Gram-staining of the buffy coat of the peripheral blood or the exudate from purpuric skin lesions was carried out in only 6 of the 26 cases but yielded positive results in all but 1. It is concluded that a diagnosis of septicemia in asplenic adults can be established within a short time of presentation on the basis of statistical probability and the results of Gram-staining of the peripheral blood and exudate from the skin lesions. Prevention appears to be the cornerstone of management because of the variable interval from splenectomy to the onset of the syndrome and the high mortality.

Electrocardiograph course.

Instruction in electrocardiogram interpretation was provided for students by distributing complete electrocardiograms to them at the beginning of the week, for nine weeks, followed by analysis by an instructor at the end of the week. This problem-solving method required minimal instruction in theory and lecture time. Skills in interpretation were promoted by teaching recognition of specific electrocardiographic patterns and their differential diagnosis rather than electrocardiogram aberrations produced by particular diseases. Reinforcement was provided by the frequent repetition of similar electrocardiograms during the course. This course was evaluated by examining students before and after the course and comparing their results with those of general internists who took the same examination. The students significantly improved their mean score and scored significantly higher than the general internists.

Management of anemia in a general city hospital: value of chart review in establishing deficiencies in care.

A retrospective review was done of the charts of 50 persons admitted to hospital for investigation of primary anemia. The duration of hospital stay was considered excessive for 80% of the patients and investigation was considered excessive for 34%. Nevertheless, underdiagnosis or misdiagnosis by the time of discharge was evident in 48% and was the result of inadequate investigation or faulty analysis of the results or both. Even when the type of anemia was established, investigations to determine the cause of specific deficiencies were frequently inadequate. Understandably treatment was inadequate for undiagnosed or misdiagnosed conditions but it was also inadequate for many correctly diagnosed conditions. Parenteral administration of iron was prescribed more often than oral administration, and 30% of patients with iron deficiency anemia failed to receive iron by either route. Most patients with vitamin B12 deficiency anemia received treatment late. Blood transfusion was given to 40% of patients but could be justified in only 16%.