A change of culture: reducing blood culture contamination rates in an Emergency Department.

Blood cultures are an important investigation to help tailor effective management for patients with severe sepsis. Frequent contaminated samples increase laboratory workload and can delay or cause incorrect changes to patient management. This can prolong patient hospitalisation, increase the risk of harm and increase cost to health boards. Current guidelines advocate a contamination rate of 2-3%. From January 2013 to November 2014 inclusive, the contamination rate was 4.74% in our Emergency Department, responsible for initial management and investigation of over 40 cases of sepsis per month. A Quality Improvement team was created to try to reduce contamination rates to the recommended target. An initial baseline survey of local staff showed good understanding of when to obtain a blood culture but there was variability in the methods and equipment used. A project was then conducted which focused on rationalising and standardising equipment and technique for blood culture sampling along with staff education to support this change. A simple department target of 30 days free from a contaminated blood culture was created which, if achieved, would ensure a contamination rate of less than 3%. This was supported by ongoing surveillance of contamination rates and investigation of contaminated sample cases. We were able to then identify high risk patients and factors which increased the chance of blood culture contamination. This allowed us to formulate solutions to help reduce the risks of contamination. Department achievements and learning points to help prevent further contamination were fed back positively to all staff. This project operated for 12-months and successfully reduced local contamination rates to 2.0%.

A review of the classification of Dupuytren's disease.

Although much has been published about the treatment of Dupuytren's disease, there is no clear consensus regarding the most effective form of treatment. Part of this uncertainty may result from the absence of a universal method of assessing this condition. We undertook a review of the literature in order to summarize the various methods by which Dupuytren's disease has been measured and quantified. We included all articles that offered a classification or assessment system for the disease. We excluded articles that dealt solely with surgical technique (although inevitably there was some overlap). We conclude that there are many methods of assessment, but that none of them is perfect and that further work is needed in the field.

A prospective study of systemic sclerosis-related digital ulcers: prevalence, location, and functional impact.

OBJECTIVES: Although digital ulcers (DUs) are common in patients with systemic sclerosis (SSc), prevalence estimates vary, and functional impact and pathophysiology have been relatively little studied. We investigated the point prevalence of all DUs (both digital-tip and extensor) in a cohort of patients with SSc, testing the hypothesis that both digital-tip and extensor ulcers are associated with functional impairment. METHOD: Over a 12-month period, patients attending an SSc clinic for annual review were assessed by specialist nurses: active DUs were documented and the Hand Mobility in Scleroderma (HAMIS) test performed. Patients also completed the Scleroderma Health Assessment Questionnaire (SHAQ), the Scleroderma Functional Index (SFI), and the Cochin Hand Function Scale (CHFS). RESULTS: A total of 25 active DUs (nine digital-tip and 16 extensor surface) were found in 15 of the 148 patients recruited, giving a prevalence for each ulcer type of 6% and an overall point prevalence of 10%. HAMIS scores were higher (indicating greater impairment) in those with active DUs than in those without: left hand difference 8.8 points [95% confidence interval (CI) 3.2-14.5], p = 0.002; difference significant for extensor as well as digital-tip ulcers. Active DUs were associated with higher visual analogue scale (VAS) scores for pain (p = 0.04), DUs (p < 0.001), and 'overall' assessment (p = 0.03). CONCLUSIONS: Extensor surface ulcers have the same prevalence as digital-tip ulcers in patients with SSc, and are equally disabling. Clinical trials should therefore include both categories of DUs.

Pilot evaluation of anterior dynamic ultrasound screening for developmental dysplasia of the hip in an Australian regional hospital.

INTRODUCTION: Developmental Dysplasia of the Hip (DDH) is the most common notifiable musculoskeletal birth defect in South Australia (SA). Despite routine screening by physical examination of the hips in the neonatal period and at 6 weeks of age, the risk of late diagnosis is increased in rural areas. It is assumed this is due to the examining doctors' reduced clinical expertise. Introducing Anterior Dynamic Ultrasound (ADUS) has reduced the late detection rates in Sweden to almost zero, and may benefit Australian infants in rural areas if routine screening was introduced. This study reports on a small implementation pilot in a SA regional hospital where volunteer postnatal mothers consented to their babies having ADUS examinations. METHODS: The pilot was evaluated by collecting results of physical examination, ADUS, and surveying parental impressions of the screening test. RESULTS: Hips of 86 infants underwent ADUS during the implementation pilot. Parents' perceptions were mainly very positive and indicated ADUS was an accessible and acceptable screening test. Of the hips scanned, three were found to have maximum movement of the femoral head of >3 mm and were deemed to demonstrate increased laxity. Four hips described as loose or mobile on clinical examination were found to be within normal limits of maximum mobility on ADUS. CONCLUSIONS: This study has demonstrated that a larger scale implementation project would be feasible in regional Australia, and would enable researchers to better understand how to reduce the late diagnosis rate of DDH in rural areas.

A three-step technique to correctly identify the trapezium without the need for fluoroscopic imaging.

Thumb pain secondary to degenerative arthritis of the carpometacarpal joint of the thumb is a common disabling condition. The key principles of successful basal joint arthroplasty involve trapezial excision, which is required for pain relief, with or without some form of ligament reconstruction. The majority of basal joint reconstructive procedures include partial or complete trapeziectomy, with and without some types of tendon transfer and ligament reconstruction and with or without tendon interposition and/or temporary wire stabilisation. When performing a trapeziectomy, it is important to identify the trapezium correctly before excising it. Excision of the incorrect bone during trapeziectomy for basal joint arthritis of the thumb has been reported within the NHS Litigation Authority database. We describe the senior author's routinely used three-step technique to confirm the identity of the trapezium before excision. This technique has been reliably used in over 300 cases with successful excision of the trapezium without intraoperative fluoroscopy.

Wrong-site surgery in orthopaedics.

Procedures performed at the incorrect anatomical site are commonly perceived as being relatively rare. However, they can be a devastating event for patients and doctors. Evidence from the United Kingdom and North America suggests that wrong-site, wrong-procedure and wrong-patient events occur more commonly than we think. Furthermore, their incidence may be increasing as NHS Trusts increase the volume and complexity of procedures undertaken in order to cope with increasing demands on the system. In previous studies from North America orthopaedic surgery has been found to be the worst-offending specialty. In this paper we review the existing literature on wrong-site surgery and analyse data from the National Patient Safety Agency and NHS Litigation Authority on 292 cases of wrong-site surgery in England and Wales. Orthopaedic surgery accounted for 87 (29.8%) of these cases. In the year 2006 to 2007, the rate of wrong-site surgery in England and Wales was highest in orthopaedic surgery, in which the estimated rate was 1:105,712 cases.

Hand function after high dose rate brachytherapy for squamous cell carcinoma of the skin of the hand.

AIMS: Current recommendations for the treatment of squamous cell carcinoma of the hand are almost unanimously in favour of ablative surgery. However, many of the patients are frail and elderly, and surgical techniques frequently involve skin grafts or amputation of digits. A non-invasive method of treatment is, therefore, often preferred. Radiotherapy using a brachytherapy technique is a well-established option. This study investigated whether patients found the treatment acceptable and assessed the outcome of treatment in terms of local control, cosmesis and hand function. MATERIALS AND METHODS: Twenty-five patients who underwent mould brachytherapy using a microselectron high dose rate radiotherapy device were available for assessment. We assessed the functional status of the hand and fingers by means of the Disability of Arm, Shoulder and Hand and Michigan Hand Outcomes questionnaires. We examined the hand to assess the severity of post-radiation stigmata. We enquired as to patient acceptability of treatment and outcome. RESULTS: Of 25 patients who agreed to participate, the fingers were affected in 15 and the dorsum of the hand in 10. The mean age at the time of radiotherapy was 69 years (range 50-87). There were no significant differences in parameters, such as range of motion of fingers and wrist, hand/finger grip strength, between the treated and opposite sides. Sensation, including two-point discrimination, was not significantly different from the untreated hand. Seventeen patients had minor skin changes. No patient found the treatment painful or unacceptable. Twenty patients were very satisfied and five patients were moderately satisfied with the cosmetic result. CONCLUSIONS: We conclude that high dose rate brachytherapy is a safe and simple alternative to surgical treatment for squamous cell carcinoma of the hand, as it is not only successful in eradicating tumour, but also preserves hand function.

The effect of tourniquet padding on the efficiency of tourniquets of the upper limb.

We report the effect of padding on the efficiency of the pneumatic tourniquet for the upper limb. Varying thicknesses of two commercially-available types of orthopaedic padding (Cellona and Velband) were applied to the arms of 20 volunteers, with three pressure transducers placed directly beneath the padding. A tourniquet was positioned over the padding and inflated to 220 mmHg. Significant reductions in the transmitted pressure were recorded from the transducers with both padding materials. With eight layers of padding, reductions in pressure of 13% (1% to 26%) and 18% (7% to 35%) were seen with Cellona and Velband, respectively. The reduction in pressure with Velband padding correlated with increasing arm circumference (Pearson's correlation coefficient 0.711, p < 0.001). Studies to date have examined how arm circumference affects the required tourniquet inflation pressure. Our study is the first to investigate the effect of the padding and the findings suggest that using more than two layers results in a significant reduction in the transmitted pressure.

Management of intra-articular fractures of the proximal interphalangeal joint by internal fixation and bone grafting.

INTRODUCTION: Intra-articular fractures of the proximal interphalangeal joint are usually treated by one of many methods of external fixation, but this does not restore the articular surface. We describe a procedure where bone grafting and internal fixation are used to restore the articular surface. PATIENTS AND METHODS: A prospective study was conducted in which three patients underwent surgical treatment for this fracture. We describe a surgical procedure where bone graft harvested from the distal radius is packed through a diaphyseal window to restore the articular surface. This is followed by internal fixation with mini-screws. RESULTS: The average follow-up was 61 months. At last follow-up the average arc of movement of the proximal interphalangeal joint was 100 deg and the average Disability of the Arm, Shoulder and Hand (DASH) Score was 2. Postoperative radiographs showed restoration of the articular contour in all three patients. CONCLUSION: The surgical technique described addresses the issues of restoration of the articular surface and permits early mobilisation. The results for our group are excellent and compare favourably with those achieved using external fixators described in the literature.

A calibrated gray scale for forensic ultraviolet photography.

The human eye is an important tool for observing evidence, and visual evidence in turn may be documented onto a photographic medium. The human eye is generally sensitive only to a narrow band of the electromagnetic spectrum from about 700 nm (red) to about 400 nm (violet/blue). It is possible to extend the range of radiations over which evidence may be documented by using the natural ultraviolet sensitivity of photographic films. However, photographing evidence with ultraviolet radiation ultimately involves presenting the information to subjects who may have no prior experience at viewing these wavelengths. This study shows that it is necessary to use a calibrated ultraviolet reflecting gray scale to allow meaningful interpretation of results.

Controlled trial of distal radial fractures treated with a resorbable bone mineral substitute.

This randomized trial compared the use of hydroxyapatite cement with Kapandji wiring in distal radial fractures. Two groups of nine patients with distal radial fractures were either treated by reduction and fixation with wires or insertion of the cement into the fracture void. There was no difference between the groups before operation, on reduction or at day 1. Dorsal angle in the hydroxyapatite group was significantly worse at 6, 12 and 26 weeks. Grip strength and palmar flexion were poor in the hydroxyapatite cement group. All the clinical parameters and X-ray variables were worse at 12 and 26 weeks in the hydroxyapatite cement group. We conclude from this trial that there is nothing to support the use of this hydroxyapatite cement, without the use of additional fixation, in distal radial fractures.

Aedes aegypti survival and dispersal estimated by mark-release-recapture in northern Australia.

The survival and dispersal of adult Aedes aegypti were estimated in northern Australia where sporadic outbreaks of Ae. aegypti-borne dengue viruses have occurred in recent years. Standard mark-release-recapture methods were used. In addition, a new sticky trap was used to capture the mosquitoes. Prior to the field study, the survival and effect of marking Ae. aegypti with fluorescent powder were determined in the laboratory. Mortality was age-dependent and the marked cohorts had higher survival rates than the untreated cohorts. Recapture rates of 13.0% and 3.6% over a seven-day period were achieved for two batches of marked Ae. aegypti released simultaneously at the field site. More males than females were recaptured although the proportion of females increased with time. The probability of daily survival was 0.91 and 0.86 for the blue- and pink-marked females, respectively, and 0.57 and 0.70 for the blue- and pink-marked and males, respectively. The mean distance traveled of recaptured Ae. aegypti was 56 m and 35 m for females and males, respectively. The maximum observed distance traveled of 160 m was the same for both sexes. The warm to hot and dry climatic conditions may have restricted the dispersal of released mosquitoes in this study. The frequency of recaptures at certain trap locations suggested that shade, wind, and the availability of hosts affected the distribution of Ae. aegypti within the study site.

Disease management ... drug data debate.

Desperately seeking a new way to generate profits, pharmacy benefit managers are trying to sell employers and HMOs on the notion of using their mountains of drug-claim information to manage chronic diseases. But skeptics point out that prescription data tell only part of the treatment story.