The quality of perioperative care: development of a tool for the perceptions of patients.

AIM OF THE STUDY: To find out how surgical hospital patients (n=874) perceived the quality of perioperative care they received in an operating department and in the recovery room. BACKGROUND: Patients' perceptions of the perioperative care have not been included systematically in the improvement of the care. Accordingly, there is no standardized, valid, and reliable instrument or system in common use that we could use for the evaluation. The nursing care in operating departments has an important role in modern health care, and therefore more research concerning perioperative care quality is needed urgently and the development of the measurement tool is urgent. METHOD: The data were collected using a structured questionnaire in five operating departments in southern Finland during 1998. RESULTS: Physical activities (such as pain management and temperature maintenance) were rated as excellent, as were staff characteristics and the physical and social environment. The most critical comments were made with regard to supporting patient initiative, encouragement and educational activities. Patients stated they would have liked more information and it was felt that they should have been encouraged to ask more questions about unclear matters. Some of the patients said they had only very limited influence over their own care. The patients were very pleased with their care in the recovery room. There were only minor differences between the views of patients from different departments. CONCLUSIONS: Overall the quality of care was considered extremely good, but comparisons of different quality categories did reveal some problems. Although it has already proved to be a useful tool, the questionnaire needs to be developed and tested further.

Corticosteroid therapy and need for hospital care in wheezing preschool children.

OBJECTIVES: To study the frequency of corticosteroid therapy and the use of inpatient care for preschool children with wheezing in two regions in Finland. METHODS: The Finnish Social Insurance Institution database on refundable asthma medication indicated that 1.18% of children in Tampere and 2.37% in Turku used inhaled corticosteroids regularly. To clarify the difference, hospital records of 800 randomly chosen 0.5-6.9-year-old children who had been treated for wheezing in Tampere or Turku University Hospital during 1995-1996 were retrospectively analysed. RESULTS: The incidences of wheezing-related emergency room (ER) index visits were 11.0 visits/year/1000 children both in Tampere and Turku. Oral corticosteroids were given to 2.5% versus 24.2% of children in ER and 10.6% versus 89.7% in hospital ward in Tampere and Turku, respectively. Hospitalisation rates were 44.8% in Tampere and 36.8% in Turku (95% confidence interval for the difference 1.2-14.8%). In both regions, children with prior inhaled corticosteroid therapy needed less inpatient care. Mean duration of hospitalisation was 3.4 days in Tampere and only 1.4 days in Turku. Recurrent visits in 6 months were more common in Tampere. CONCLUSIONS: There were marked regional differences in the management of preschool children with wheezing. On a population level, frequent use of corticosteroid therapy was associated with reduced hospital admissions.

Local heroes beat national champions: quality improvement in Finnish health care.

UNLABELLED: FINNISH HEALTH CARE: Although health care services in Finland are organized uniformly throughout the country, they, along with the application of total quality management (TQM)/continuous quality improvement (CQI), are the responsibility of municipalities. CASE 1: At the Helsinki City Health Organization, top management launched an organizationwide quality improvement (QI) initiative in 1993, entailing 150 CQI projects. Yet top and middle managers were not sufficiently dedicated to the initiative to provide adequate support to many of the quality projects. Only "islands of activity" were spotted. CASE 2: A physician in the pediatrics department of a hospital helped initiate CQI projects--for improvements in administration of x-rays for patients with antebrachium fractures, transport of samples to the microbiology laboratory, and admissions of patients with acute infectious disease. Successes led senior management in the hospital federation to issue a quality policy based on CQI management, showing the power of the good example. CASE 3: The first launch of CQI at the Helsinki University Central hospital was part of a management development project that did not have the full support of senior management and that, consequently, failed. A second initiative undertaken a year later, the quality council, was more successful. CASE 4: At a local center for social services and primary care, quality projects have strengthened the organization's team and network structures across two professional cultures. DISCUSSION: The four cases provide insight into the diffusion of TQM/QI and implementation strategies on the local level.

Diagnosis of Helicobacter pylori infection by using pyloriset EIA-G and EIA-A for detection of serum immunoglobulin G (IgG) and IgA antibodies.

We evaluated the performance of new enzyme immunoassay (EIA) kits (Pyloriset; Orion Corporation, Orion Diagnostica, Espoo, Finland) for the detection of immunoglobulin G (IgG) and IgA antibodies to Helicobacter pylori in serum. Serum samples from 195 patients with upper abdominal complaints were collected. Biopsy specimens of the gastric mucosae were taken for histological analysis and bacterial culture. The sensitivity, specificity, and positive and negative predictive values, and efficacy of the Pyloriset EIA-G in detecting IgG antibodies to H. pylori were 92, 84, 88, 90, and 89%, respectively, when compared with those of the reference methods used. The corresponding data for detection of IgA antibodies were 80, 89, 89, 79, and 84%, respectively. The overall prevalence of defined H. pylori positivity was 54%. Moreover, the antibody tests showed a very good correlation with the biopsy findings. IgG antibodies were found in 93% of sera from patients with documented gastritis and H. pylori positivity, whereas only 4% of the sera from patients with documented gastritis and H. pylori-negative patients was positive. The results obtained for IgA antibodies were 81 and 6%, respectively. We conclude that the Pyloriset EIA-G, the test for IgG antibodies, is a good and reliable test for the detection of antibodies to H. pylori and as an indication of H. pylori infection. The determination of IgA antibodies may be used as a test that complements the IgG antibody assay.

Long-term effects of syrup medications for recurrent otitis media on the dental health of 6- to 8-year-old children.

The dental response to repeated antimicrobial and antihistamine medications was studied by comparing the dental health of 64 adenoidectomized children 5 years after surgery to that of 212 untreated controls. Annual dental recordings starting from the age of 3 years were obtained from health care centers. As expected, the proportion of children who had several (> or = 11) syrup medications was significantly higher (p < 0.001) in the adenoidectomized than in the control group. Sucrose-containing syrup medications were prescribed twice as often for the children of the adenoidectomized as for the control group (p < 0.001). However, the average amount of antimicrobial syrup medications prescribed was 19.2 +/- (SD) 13.0 per child for the adenoidectomized as compared to 8.5 +/- 8.3 for the control children (p < 0.001). The dmf value of the adenoidectomized children at the age of 3 years (mean +/- SEM: 0.5 +/- 0.1) was significantly (p < 0.005) lower than that of the controls (1.1 +/- 0.2). The difference was still significant (p < 0.01) at the age of 4 years, but disappeared thereafter. In conclusion, the antibacterial syrup medication seemed to be associated with a significant decline in dental caries at first. The simultaneous use of antihistamines was, however, thought to delay normal tooth maturation, so that after discontinuation of the antimicrobial medication, accelerated formation of new carious lesions took place.

Glutathione and glutathione-metabolizing enzymes in the erythrocytes of healthy children and in children with insulin-dependent diabetes mellitus, juvenile rheumatoid arthritis, coeliac disease and acute lymphoblastic leukaemia.

Oxidative biotransformation of xenobiotics and endogenous substances involves glutathione in reduced form as an integral component through two mechanisms: glutathione peroxidase catalysing the reduction of hydrogen peroxide and organic hydroperoxides, and glutathione-S-transferases catalysing the conjugation of oxygenated derivatives with glutathione. We studied glutathione and glutathione-related enzyme activities in haemolysed venous blood samples from 49 healthy children and from 11 children with diabetes mellitus, 10 children with rheumatoid arthritis, seven children with active coeliac disease, and seven children with acute lymphoblastic leukaemia. Among the healthy children glutathione content and the activities of glutathione reductase, glutathione peroxidase, and glutathione-S-transferase were unrelated to sex; age-dependent differences were also minor. The patients with diabetes mellitus had decreased activity of glutathione reductase. The patients with acute lymphoblastic leukaemia had increased activity of both glutathione peroxidase and glutathione-S-transferase, possibly reflecting an adaptive response to free-radicals. The patients with active coeliac disease had control levels of all measured parameters of glutathione-related reactions indicating, since we earlier found decreased activities of glutathione peroxidase in intestinal mucosa of celiacs, that blood may not always reflect tissue-specific changes.

Iron deficiency in coeliac disease is mild and it is detected and corrected by gluten-free diet.

In 54 children with coeliac disease, mild iron deficiency anaemia or evidence of iron deficiency without anaemia were common at the time of diagnosis. Treatment with a gluten-free diet without iron medication eliminated all evidence of iron deficiency and completely normalized laboratory values. Subsequent challenge with gluten resulted in the rapid reappearance of suboptimal iron balance as evidenced by a decrease in serum ferritin concentration.

Mucosal biotransformation rates in the small intestine of children.

Biotransformation of ingested xenobiotics is known to take place in the gastrointestinal mucosa of laboratory animals and adult humans as well as in the liver. We studied the activities of aryl hydrocarbon hydroxylase, epoxide hydrolase, and glutathione peroxidase in 242 peroral small intestinal biopsy samples of children aged eight months to 18 years: 201 with normal histology, 21 with partial villous atrophy, and 20 with severe villous atrophy. All these enzymes were detectable even in the youngest children. The aryl hydrocarbon hydroxylase activity was age dependent, while the other measured enzyme activities were not related to the age of the patients. The aryl hydrocarbon hydroxylase activity was not related to the mucosal histology, but the epoxide hydrolase and glutathione peroxidase activities were diminished in samples with severe villous atrophy as compared with normal mucosa. This suggests that small intestinal mucosa with villous atrophy may produce oxidated, reactive metabolites, but further metabolism into detoxication products is decreased. This may expose persons with mucosal atrophy to possible harmful effects of environmental xenobiotics entering the body even at low doses.

Infantile colic and feeding.

In a double blind crossover study 10 children with infantile colic were fed breast milk and cow's milk formula, untreated and treated with lactase. Colic was present on 71% of breast milk and 89% of cow's milk days. Daily duration and severity of colic did not differ for milk preparations.

Antibodies to gliadin by ELISA as a screening test for childhood celiac disease.

The sera of 309 children who were subjected to jejunal biopsy were tested for antigliadin antibodies (AGA) with enzyme-linked immunosorbent assay (ELISA) in order to evaluate the usefulness of this test as a screening test for childhood celiac disease (CD). Thirty-one children had flat intestinal mucosa later confirmed to be due to CD. Ninety percent of these children had significantly elevated levels of IgA class AGA and 94% had significantly elevated levels of IgG class AGA as compared to standard references. Two hundred and seventy-eight children had normal villous structure. In this group, 37 children out of 271 (seven excluded because of selective IgA deficiency) had elevated levels of IgA class AGA, and 93 children out of 278 had elevated levels of IgG class AGA. We conclude that ELISA-AGA is suitable as a screening test for childhood CD.

Risk factors for recurrent otitis media.

Risk factors for recurrent otitis media were studied in 115 otitis-prone children. A group of 323 children was used as controls. The care of children in day care centers, parental smoking and a low socioeconomic status of the family were associated with recurrent otitis media. The duration of breast feeding, the child's age at introduction of cow's milk-based feeding and allergy were not associated with recurrent otitis media.

Breast feeding, cow milk feeding, and allergy.

Information about every 10th child aged 14 to 38 months was collected by means of a questionnaire in Turku, Finland in March, 1983. This paper reports on the occurrence of allergy in relation to the duration of breast feeding and to the age of the child when cow milk feeding was started. The average duration of breast feeding was 5.7 months and the average age at the introduction of cow milk-based products was 4.3 months. Allergy was reported in family members of 47.6% of the children. In 30.3% the child himself was reported allergic. The occurrence of allergy was unaffected by the duration of breast feeding and the age at introduction of cow milk feeding.

Breast-feeding and social factors.

Information about every tenth child aged 14 to 38 months was collected by means of a questionnaire in Turku, Finland in March, 1983. This paper reports on duration of breast-feeding and its relation to social factors. The average duration of breast-feeding was 5.7 months. Length of breast-feeding was unaffected by sex, number of siblings, and birth order among siblings. The socioeconomic status of the father was associated with duration of breast-feeding: children in high status families were breast-fed longer than children in low status families. Mothers with occupations in the health service, education, and the social sector breast-fed longer than mothers in other occupations. Mothers who were working at the time of the study had breast-fed longer than housewives. For further promotion of breast-feeding, information must be made more effective in the lower social groups and among fathers.

Infantile colic: occurrence and risk factors.

The purpose of this work was to study the appearance of infantile colic and gas discomfort and to learn whether these problems are associated with factors in the child's social environment, allergic symptoms, or feeding. The study was made retrospectively by means of a questionnaire which was sent to mothers of every tenth child aged 14 to 38 months in Turku, Finland. Forty percent of the children, as many boys as girls, had colic or gas problems in early infancy, so severe in 20% that drug therapy was used. First born children in the family more often had colic and gas problems than did subsequent children. Siblings of colicky children had colic and gas problems more often than did siblings of the children who had no colic or gas problems. Neither family history or symptoms of allergy, duration of breast-feeding, mother's consumption of plain cow's milk during lactation, nor the age of introduction of cow's milk to the child were associated with the occurrence of colic. Children with colic grew as well as children without. However, their night sleep was more often disturbed by awakenings than the night sleep of children without colic or gas problems in early infancy.