Measurement of process as quality control in the management of acute surgical emergencies.

BACKGROUND: Quality of care measured by adverse events cannot address errors of process that have no adverse outcomes. The aim of this study was to determine whether process could be used to assess quality of care and whether process analysis could be used to assess interventions designed to improve quality. METHODS: A single-centre prospective cohort study was performed over 12 weeks in an acute surgical admission unit. Data were collected prospectively for the first 24 h of admission on three aspects of process: documentation, general management and presentation-specific criteria. After a period of observation, the impact of three interventions (active observation, increasing awareness and issuing a job description) on the mean number of process errors per patient (process score) was compared. RESULTS: The analysis was based on 566 patients admitted with general surgical pathology. Awareness of being observed failed to improve the process score. Interventions that increased awareness of process reduced the overall process score from 4.79 to 2.38 errors per person (P < 0.001). The mean overall process score in patients with an adverse event was twice that of patients who did not have an adverse event (5.74 (95 per cent confidence interval 4.03 to 7.45) versus 3.43 (3.19 to 3.66)). CONCLUSION: Process can be measured objectively and used as a measure of quality of care. Interventions to increase awareness reduced process error rates and adverse events.

Should pre-operative troponin be a standard requirement in patients undergoing major lower extremity amputation?

OBJECTIVES: The objective of this study was to ascertain the benefit of routine pre-operative cardiac troponin I (cTnI) measurement in patients undergoing major lower extremity amputation for critical limb ischaemia. DESIGN: This was a prospective, blinded observational study. METHODS: All patients scheduled for lower extremity amputation, without evidence of unstable coronary artery disease were recruited prospectively over a period of 1 year. In addition to routine pre-operative evaluation, a blood sample was taken for measurement of serum cTnI. Post-operative screening was conducted for cardiac events with patients followed up to 6 weeks. RESULTS: Ten of the 44 patients included suffered a non-fatal myocardial infarction or died from a cardiac cause post-operatively. A rise in pre-operative cTnI was associated with a very poor outcome (two cardiac deaths and one post-operative myocardial infarction) and was the only significant predictor of post-operative cardiac events. CONCLUSION: Routine pre-operative cTnI measurement may be of use to identify patients at high risk of cardiac complication who would benefit from optimization of cardiac status or in whom surgery could be deferred.

A time series evaluation of California's 1982 driving-under-the-influence legislative reforms.

This study evaluated the impact of 1982 legislative reforms, including enhanced penalties, greater sentencing uniformity, and the introduction of an illegal per se standard, on California's driving-under-the-influence (DUI) countermeasure system. Intervention time series analysis was used to evaluate the general deterrent effects of these laws, as measured by alcohol-related fatal and injury accident rates, both statewide and in counties sharing similar demographic and enforcement patterns. In combination with the legislative effects, analyses also assessed the significance of prelegislative publicity associated with an emerging antidrunk driving sentiment largely popularized by the formation of Mothers Against Drunk Driving (MADD). Both implementation of the DUI statutes and the publicity and societal dynamics surrounding the creation of MADD were found to be associated with reductions in subsequent alcohol-related fatal and injury accident rates, with evidence of more pronounced effects among injury accidents.

Glasgow marathons 1982-1987. A review of medical problems.

The race statistics, whether conditions and incidence of medical problems for the six consecutive years of the Glasgow Marathon are reviewed. The results suggest that the popularity of marathon running is declining but that the competitors are becoming more experienced, seeking medical assistance earlier and, as a result, experiencing fewer and less serious problems at the finish. The effect of weather conditions on the runners' performance is discussed.

Changes in anti-endotoxin-IgG antibody and endotoxaemia in three cases of gram-negative septic shock.

Circulating endotoxin levels and IgG antibodies to a range of Gram-negative bacterial lipopolysaccharides (LPS) (endotoxins) of different sizes and structures were measured daily in three cases of septic shock. There was an inverse relationship between endotoxin levels and cross-reactive antibodies to the core glycolipid (CGL) region of lipopolysaccharide. This suggests that antibody to LPS-CGL was initially consumed by a superabundance of endotoxin, and that a resurgence of intrinsic anti-LPS-CGL antibody levels may be associated with a reduction of circulating endotoxin. The implications of these findings for passive antibody therapy of septic shock are discussed.

Outcome of TIAs of unknown aetiology following non-invasive evaluation.

A proportion of patients with apparently classical transient ischaemic attacks (TIA), will have no cause for their symptoms discovered when investigated. We have reviewed 74 patients with TIA and a further 28 with amaurosis fugax whose symptoms remained unexplained following non-invasive carotid evaluation using pulsed Doppler imaging with spectrum analysis. After a mean follow-up of 31.7 months, 48.6% of TIA patients were symptom free, 36.5% had experienced recurrent symptoms and 8.1% had suffered a stroke. Among the patients with amaurosis fugax the equivalent figures were 32.1% symptom free, 42.7% recurrent symptoms, and 10.7% stroke. These figures suggest that unexplained TIAs do not necessarily have a benign prognosis and more extensive or repeated investigation of these patients is warranted.

Critical abdominal sepsis.

Intra-abdominal sepsis is a heterogeneous condition which in its severe forms carries a high mortality. The systemic consequences of established major infection are the result of a complex pathophysiology whose mechanisms are imcompletely understood. It is clear that early appropriate therapy is vital in minimizing effects of intra-abdominal infection and to this end early recognition of sepsis is important. Clinical examination may be unhelpful in difficult cases and special investigations may aid diagnosis; a high index of suspicion is mandatory. Surgery is the mainstay of therapy but may be inadequate and supportive measures are an essential adjunct.

Provision of facilities for secondary transport of seriously ill patients in the United Kingdom.

A survey by questionnaire of 280 hospitals with general intensive care units was carried out to find out what facilities were provided for secondary transport of seriously ill patients in the United Kingdom. Replies were received from 181 units. Extrapolating from the survey data showed that about 10,000 patients were transported each year, although many units transferred only a few patients. An appreciable minority of units reported that facilities for secondary transport were inadequate and many were obliged to send inexperienced medical staff with patients. Almost half of the respondents thought that arrangements for transfer were unsatisfactory, but only a tenth said that they delayed or refused transfer for this reason. This undoubtedly reflects a policy of "making do" despite inadequate resources. We believe that these results support the concept of regional transport services, where each major unit would be adequately equipped and staffed and unnecessary duplication of resources avoided.

Surgical management of bleeding gastric ulceration.

In a nine-year period from 1977 to 1985 sixty-one patients underwent surgery for bleeding gastric ulceration in the Western Infirmary, Glasgow. Nineteen patients were treated by partial gastrectomy, twenty-two had undersewing of the ulcer plus vagotomy and drainage and twenty had undersewing alone. Mortality in the three groups was 26, 45 and 10 per cent respectively. All groups of patients were similar in terms of age, severity of haemorrhage, delay before surgery and grade of surgeon performing the procedure. Out-patient follow-up (mean: 37 months) of patients treated by undersewing alone revealed that 73 per cent were symptom free. Treatment of bleeding gastric ulceration by undersewing alone is effective and should be considered in patients who require surgery.

Postoperative intra-abdominal sepsis.

Postoperative intra-abdominal sepsis carries a high mortality. Diagnosis by clinical examination is often difficult, and imaging techniques may be helpful. Diagnostic laparotomy should be considered early, even in the absence of localizing signs. The use of aggressive surgical techniques may improve prognosis. The timing of surgical intervention is as important as the technique. Early diagnosis and treatment is particularly crucial in critically ill patients.

Diffuse villous adenoma of the pancreatic duct.

A case of diffuse villous adenoma affecting the pancreatic duct in a 31-year-old woman is described. The diagnosis was made by endoscopic retrograde cholangiopancreatography and the patient treated by proximal pancreatectomy. One year later the patient is alive and well. Papillary tumors affecting the pancreatic duct have rarely been described. All previous cases have occurred in middle-aged or elderly patients. None of the previously described benign tumors was as extensive as the one reported here. The possible pre-malignant potential of such tumors is discussed.