Use of a digital delirium pathway and quality improvement to improve delirium detection in the emergency department and outcomes in an acute hospital.

BACKGROUND: delirium is a common condition associated with hospital admission. Detection and diagnosis is important to identify the underlying precipitating cause and implement effective management and treatment. Quality improvement (QI) methodology has been applied in limited publications. There are even fewer publications of the role of development of the electronic health record (EHR) to enhance implementation. METHODS: we used QI methodology to improve delirium detection in the emergency department (ED). Plan Do Study Act (PDSA) cycles could be broadly categorised into technology, training and education and leadership. As part of the technology PDSA an electronic delirium pathway was developed as part of an NHS England digital systems improvement initiative (NHS England Global Digital Exemplar). The electronic pathway incorporated the 4AT screening tool, the Confusion Assessment Method, the TIME delirium management bundle, investigation order sets and automated coding of delirium as a health issue. RESULTS: development of the EHR combined with education initiatives had benefit in terms of the number of people assessed for delirium on admission to the ED and the total number of people diagnosed with delirium across the organisation. The implementation of a delirium pathway as part of the EHR improved the use of 4AT in those 65 years and over from baseline of 3% completion in October 2017 to 43% in January 2018. CONCLUSION: we showed that enhancement of the digital record can improve delirium assessment and diagnosis. Furthermore, the implementation of a delirium pathway is enhanced by staff education.

The role of appropriate diagnostic testing in acute respiratory tract infections: An antibiotic stewardship strategy to minimise diagnostic uncertainty in primary care.

Antibiotic resistance has increased worldwide to the extent that it is now regarded as a global public health crisis. Interventions to reduce excessive antibiotic prescribing to patients can reduce resistance and improve microbiological and clinical outcomes. Therefore, although improving outpatient antibiotic use is crucial, few data are provided on the key interventional components and the effectiveness of antibiotic stewardship in the primary care setting, in South Africa. The reasons driving the excessive prescription of antibiotics in the community are multifactorial but, perhaps most importantly, the overlapping clinical features of viral and bacterial infections dramatically reduce the ability of GPs to distinguish which patients would benefit from an antibiotic or not. As a consequence, the need for tools to reduce diagnostic uncertainty is critical. In this regard, besides clinical algorithms, a consensus of collaborators in European and UK consortia recently provided guidance for the use of C-reactive protein point-of-care testing in outpatients presenting with acute respiratory tract infections (ARTIs) and/or acute cough, if it is not clear after proper clinical assessment whether antibiotics should be prescribed or not. A targeted application of stewardship principles, including diagnostic stewardship as described in this review, to the ambulatory setting has the potential to affect the most common indications for systemic antibiotic use, in that the majority (80%) of antibiotic use occurs in the community, with ARTIs the most common indication.

Emergence of OXA-48 and OXA-181 carbapenemases among Enterobacteriaceae in South Africa and evidence of in vivo selection of colistin resistance as a consequence of selective decontamination of the gastrointestinal tract.

This study reports on the emergence of OXA-48-like carbapenemases among isolates of Enterobacteriaceae in South Africa. In addition, the emergence during therapy of a colistin-resistant OXA-181-producing Klebsiella pneumoniae isolate was documented following selective digestive tract decontamination with oral colistin, which is therefore strongly discouraged.

The spread of carbapenem-resistant Enterobacteriaceae in South Africa: risk factors for acquisition and prevention.

New, effective antibiotics are only likely to become available in 15 - 20 years. To prevent deaths from untreatable Gram-negative infections in South Africa, the rights of any doctor, whether in general or in hospital practice, to indiscriminately prescribe whatever antibiotic they wish, and in whatever fashion, must be challenged. Furthermore, although prevention of the emergence and subsequent spread of carbapenem-resistant Enterobacteriaceae (CRE) has focused on acute and chronic care facilities and inter alia on antibiotic exposure in these institutions, CRE may soon become an issue within entire communities, highlighting a role for public health authorities in CRE prevention efforts.

Superior Detection of Pathogens in Synovial Fluid by the Bactec 9240 Peds Plus/F System Compared to the Conventional Agar-Based Culture Method

Abstract:To improve culture yield in cases of possible septic arthritis; we compared culture of joint fluid aspirates on conventional agar-based media to culture in Bactec 9240 Peds/Plus F blood culture bottles with and without the addition of fastidious organism supplement (FOS). Over a period of 21 months; we analysed 123 synovial fluid samples and isolated 20 pathogens. The Bactec methods proved superior by yielding more pathogens than the conventional culture method (p=0.074). However; this method also yielded more contaminants within the first three days of incubation (p=0.027). All contaminants detected after three days of incubation were the result of overgrowth on conventional method agar plates. The Bactec methods provided clinicians with a positive pathogen result one day earlier than the conventional counterpart (p=0.001). Four isolates of Neisseria gonorrhoeae were only cultured with the Bactec method. No significant benefit was demonstrated by supplementing blood culture bottles with FOS. We recommend that whenever infection by fastidious organisms is suspected; synovial fluid aspirates should be cultured using automated blood culture systems to increase the culture yield and to decrease the time to detection

An audit on the reporting of critical results in a tertiary institute.

BACKGROUND: Critical result reporting is a requirement for accreditation by accreditation bodies worldwide. Accurate, prompt communication of results to the clinician by the laboratory is of extreme importance. Repeating of the critical result by the recipient has been used as a means to improve the accuracy of notification. Our objective was to assess the accuracy of notification of critical chemical pathology laboratory results telephoned out to clinicians/clinical areas. We hypothesize that read-back of telephoned critical laboratory results by the recipient may improve the accuracy of the notification. METHODS: This was a prospective study, where all critical results telephoned by chemical pathologists and registrars at Tygerberg Hospital were monitored for one month. The recipient was required to repeat the result (patient name, folder number and test results). Any error, as well as the designation of the recipient was logged. RESULTS: Of 472 outgoing telephone calls, 51 errors were detected (error rate 10.8%). Most errors were made when recording the folder number (64.7%), with incorrect patient name being the lowest (5.9%). Calls to the clinicians had the highest error rate (20%), most of them being the omission of recording folder numbers. CONCLUSION: Our audit highlights the potential errors during the post-analytical phase of laboratory testing. The importance of critical result reporting is still poorly recognized in South Africa. Implementation of a uniform accredited practice for communication of critical results can reduce error and improve patient safety.

Potential for medical error: incorrectly completed request forms for thyroid function tests limit pathologists' advice to clinicians.

BACKGROUND: Various publications have highlighted the significance of laboratory errors in the pre- and post-analytical phases and their impact on results. Thyroid-stimulating hormone (TSH) is a first-line thyroid function test and, if abnormal, reflex thyroxine (T4) or tri-iodothyronine (T3) testing is requested, depending on clinical and medication data provided. Interpretative comments are added to all TFT results. OBJECTIVES: In view of the paucity of articles describing such errors, we audited laboratory request forms requesting thyroid function tests (TFT), received from primary care clinics and regional hospitals at our laboratory. DESIGN: We assessed 482 laboratory request forms for TFT from primary health care clinics for specific parameters. RESULTS: A total of 482 forms were analysed. Medication/s used by the patient (74.5%) and doctor's contact number (65.1%) were the most commonly incomplete parameters. Of the 123 patients with medication details, 62 (50.4%) were on thyroxine. CONCLUSIONS: There are few studies examining the frequency and impact of incomplete laboratory forms on laboratory errors, and even fewer studies examining interpretative comments accompanying clinical biochemistry results. We studied how pre-analytical errors in completing request forms may lead to incorrect interpretative comments and inappropriate reflex testing, and so influence the quality of the post-analytical phase.

Incomplete laboratory request forms: the extent and impact on critical results at a tertiary hospital in South Africa.

BACKGROUND: Research has demonstrated that most laboratory errors occur in the preanalytical phase of testing. In view of the paucity of studies examining preanalytical errors, we evaluated our laboratory request forms for the frequency and impact of incomplete data. METHODS: This study examined all request forms received at our laboratory during a five-day period. The forms were scrutinized for the presence of specific parameters. The impact of abbreviated diagnoses was analysed, as well as how lack of ward or telephone details affects the communication of critical results to clinicians. RESULTS: A total of 2550 request forms were analysed. Medication(s) used by the patient (89.6%) and doctor's contact number (61.2%) were the most incomplete parameters. No diagnosis was provided on 19.1% of forms, and when a diagnosis was present it was an abbreviated form in 37.3%. This resulted in 35.5% of diagnoses not being recorded by reception staff. Incomplete ward information was found on 4.9% of forms. In a separate search, the impact of 151 request forms (collected over a period of eight months), with incomplete ward location information and corresponding to critical results was assessed. Critical results were not communicated by telephone to clinicians in 19.9% of cases. CONCLUSION: As laboratory data influences 70% of medical diagnoses, incorrect or incomplete data provided to the laboratory could significantly impact the success and cost of overall treatment.

Fatal human infection with rabies-related Duvenhage virus, South Africa.

Duvenhage virus was isolated from a patient who died of a rabies-like disease after being scratched by a bat early in 2006. This occurred approximately 80 km from the site where the only other known human infection with the virus had occurred 36 years earlier.