Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy.

Background: Acute gallstone disease is a high-volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance. Methods: Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods. Results: Of 13 sites invited to join Chole-QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole-QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8-day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals. Conclusion: A surgeon-led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.

Antecedentes: La patología biliar aguda litiásica es una de las urgencias con más volumen de casos en cirugía general, con amplias variaciones en la calidad de la atención prestada en todo el Reino Unido. En este estudio de cohortes controlado se valoró si la participación en un enfoque colaborativo de mejora de la calidad disminuía el tiempo hasta la cirugía en pacientes con patología biliar aguda litiásica a menos de 8 días desde la presentación, de acuerdo con la guía nacional. Métodos: Se identificó a los pacientes que precisaron un ingreso hospitalario por patología biliar aguda en Inglaterra y Gales, del 1 de abril de 2014 al 31 de diciembre de 2017, a partir de datos de las estadísticas de episodios hospitalarios. Se crearon series temporales de actividad trimestral para Chole­QuIC y para todos los demás hospitales de agudos del NHS (grupo control). Se utilizó un modelo de regresión binomial negativa para comparar la proporción de pacientes sometidos a cirugía dentro de los primeros 8 días en los periodos basal y de intervención. Resultados: De los 13 sitios invitados a unirse a Chole­QuIC, 12 participaron durante toda la colaboración, que se desarrolló entre octubre de 2016 y enero de 2018. De los 7.944 ingresos, en 1.160 pacientes se realizó la colecistectomía dentro de los 8 días posteriores a su ingreso, una mejora significativa (P < 0,05) en comparación con el periodo previo a la intervención. Esto representó un cambio relativo de 1,56 (i.c. del 95%: 1,38 a 1,75) en comparación con 1,08 para el grupo de control. A nivel de cada uno de los hospitales, ocho de los 12 centros Chole­QuIC presentaron una mejora significativa (P < 0,05), y en cuatro de ellos el porcentaje de cirugía en 8 días aumentó a más del 20% de todos los ingresos urgentes, muy por encima del promedio de 15,3% para hospitales de control. Conclusión: Un enfoque colaborativo de mejora de la calidad dirigido por el cirujano mejoró la atención a los pacientes que precisan una colecistectomía urgente.

'Near-miss' hyperkalaemic cardiac arrest associated with rapid blood transfusion.

A case is presented in which a relatively modest blood transfusion resulted in acute hyperkalaemia with a 'near-miss' cardiac arrest. While transfusion-related hyperkalaemia usually occurs in association with massive transfusions, several factors may have increased the risk of such an acute reaction. A high index of suspicion is required, especially in patients with risk factors. Anaesthetists should not be lulled into a false sense of security simply because modest volumes of blood are being transfused.

Pain following craniotomy: a preliminary study comparing PCA morphine with intramuscular codeine phosphate.

We have performed a prospective randomised trial of 30 patients undergoing craniotomy to compare intramuscular codeine phosphate with patient-controlled analgesia using morphine 1 mg bolus with a 10-min lockout and no background infusion. For 24 h postoperatively, pain, nausea, Glasgow coma score, respiratory rate and sedation score were assessed. There was a wide variation in the amounts of morphine requested by the patients in the patient-controlled analgesia group in the first 24 h postoperatively (range 2-79 mg, median 17 mg). There was a small, but non-significant, reduction in pain scores in the patient-controlled analgesia group. There were no significant differences between the two groups in respect of nausea and vomiting, sedation score or respiratory rate. No major adverse effects were noted in either group. Patient-controlled analgesia with morphine is an alternative to intramuscular codeine phosphate in neurosurgical patients which merits further investigation.

Resuscitation skills amongst anaesthetists.

Resuscitation skills were assessed in a group of 24 anaesthetists of varying experience using 3 pre-determined scenarios. Seventy-nine percent of participants were found to be competent at resuscitation following the guidelines suggested by the Resuscitation Council (UK) in 1989. No one grade of anaesthetist was found to be consistently poor at resuscitation. Anaesthetists by the nature of their jobs may maintain the skills and knowledge of cardiopulmonary resuscitation as well as other groups in the hospital.

The use of ultra-low-dose aprotinin to reduce blood loss in cardiac surgery.

One hundred patients due to undergo primary cardiac surgery were prospectively randomized to receive aprotinin or placebo. In the aprotinin group, 250,000 kallikrein inhibitory units (KIU) of aprotinin were added to the cardiopulmonary bypass prime solution. A further 250,000 KIU of aprotinin were infused intravenously over 30 minutes immediately before the start of cardiopulmonary bypass. The control group received 0.9% saline in equal volumes at identical times. The study was designed to have a 90% chance of demonstrating a 30% reduction in blood loss. No significant differences were found between the two groups. The median blood loss in the aprotinin group was 750 mL (interquartile range 556 to 1025 mL, 95% confidence interval 600 to 800 mL). In the control group, the median blood loss was also 750 mL (interquartile range 500 to 988 mL, 95% confidence interval 625 to 925 mL). In the aprotinin group, 12 patients received postoperative autotransfusion of shed mediastinal blood of median volume of 665 mL (interquartile range 500 to 925 mL, 95% confidence interval 450 to 1000 mL). In the control group, 14 patients received postoperative autotransfusion of mediastinal blood of median volume of 663 mL (interquartile range 600 to 800 mL, 95% confidence interval 600 to 700 mL). Five patients in the aprotinin group and seven patients in the control group required postoperative homologous blood transfusion. Reassessment of inclusion criteria showed a 19% reduction in blood loss in patients undergoing only aortocoronary bypass receiving aprotinin compared with controls.(ABSTRACT TRUNCATED AT 250 WORDS)

The inflatable wedge: an aid to bilateral hip arthroplasty.

A reusable inflatable wedge system is described for use during bilateral hip arthroplasty. It allows rapid repositioning during the procedure, with minimal interference to the surgical field. It is robust, cheap and provides minimal compromise to surgical asepsis. It has potential for use in a variety of procedures.

Sudden death after central venous cannulation.

A previously fit 39-yr-old man was admitted with clinical findings suggestive of septicaemic shock. After routine insertion of a central venous catheter he developed electromechanical dissociation. Prolonged efforts to resuscitate the patient were unsuccessful. Post mortem examination showed a cyst arising from the tricuspid valve annulus which had prolapsed into the right ventricular outflow tract. The insertion of a central venous catheter probably caused the cyst to prolapse and cause cardiac arrest with electromechanical dissociation. This unique complication emphasises the importance of not allowing the Seldinger wire or central venous catheter to enter the heart during insertion. Correct positioning of central venous catheters during insertion is most safely confirmed by back flow of blood in the catheter and right atrial electrocardiography together with a follow up chest radiograph, rather than relying on the occurrence of cardiac arrhythmias during placement of the Seldinger wire or catheter. To avoid excessive lengths of Seldinger wire or catheter being inserted inadvertently during placement, both should be marked along their lengths.