Use of an electronic alert to identify patients with acute kidney injury.

Early intervention in the management of acute kidney injury (AKI) has been shown to improve outcomes. To facilitate early review we have introduced real time reporting for AKI. An algorithm using the laboratory computer system was implemented to report AKI for inpatients. Over 6 months there were 1,906 AKI reports in 1,518 patients: 56.3% AKI1, 26.9% AKI2 and 16.8% AKI3. 51.0% were male. Median age was 78 (interquartile range [IQR] 17) years. 62.6% were from general medical wards, 16.9% from surgical wards, 6.9% from orthopaedic wards and 5.3% from specialty wards. 8.3% were from peripheral hospitals. 31% of patients with AKI reports were clinically coded for AKI. 9% (n = 139) showed progression of AKI (mortality 42%). Patients with AKI had a significantly higher length of stay and mortality than those that did not. 4% of patients with AKI received acute renal replacement therapy (RRT). An e-alert system is feasible, allowing early identification of inpatients with AKI.

What do hospital staff in the UK think are the causes of penicillin medication errors?

BACKGROUND: Medication errors are a potential major threat to patient's health, and allergic reactions occurring in patients with known allergies are an important preventable form of adverse drug event. The use of penicillin antibiotics in patients who are allergic to penicillin, in particular, is a major concern. AIM: To survey staff attitudes and beliefs to incidents involving penicillin allergic patients who are prescribed and administered penicillin antibiotics. SETTING: A 650 bed teaching hospital in England. METHOD: Using individual and (focus) group interview proceedings with a purposive sample of doctors, nurses and pharmacists, an electronic questionnaire was administered hospital wide to all clinical staff. No reminders were issued. MAIN OUTCOME MEASURES: Clinical staff's views on the causes of penicillin medication errors. RESULTS: The electronic survey was completed by 235 members of the clinical staff. Half the respondents definitely considered themselves knowledgeable about which antibiotics contain penicillin medicines, though approximately 90 % of respondents considered that misinformation or lack of knowledge on which antibiotics contain penicillin medicines was an issue for some or most colleagues. Various organisational issues such as the use of red wrist bands, the wearing of red tabards by the nurse during the medicines round, and a busy work environment were recurrently highlighted as systems factors that could be improved upon. CONCLUSION: Our study elucidated concerns amongst clinical staff relating to the scenario of a penicillin allergic patient receiving a penicillin antibiotic. The resulting local learning and feedback about staff beliefs pertaining to this one specific type of error will be used to consider the nature and type of local action to be taken to help improve patient safety.

Hepatitis E seroprevalence in recipients of renal transplants or haemodialysis in southwest England: a case-control study.

Locally acquired HEV infection is increasingly recognized in developed countries. Anti-HEV IgG seroprevalence has been shown to be high in haemodialysis patients in a number of previous studies, employing assays of uncertain sensitivity. The aim of this study was to investigate anti-HEV IgG seroprevalence in recipients of haemodialysis and renal transplants compared to a control group using a validated, highly sensitive assay. Eighty-eight patients with functioning renal transplants and 76 receiving chronic haemodialysis were tested for HEV RNA and anti-HEV IgG and IgM. Six hundred seventy controls were tested for anti-HEV IgG. Anti-HEV IgG was positive in 28/76 (36.8%) of haemodialysis and 16/88 (18.2%) of transplant patients. HEV RNA was not found in any patient. 126/670 (18.8%) of control subjects were anti-HEV IgG positive. After adjusting for age and sex, there was a significantly higher anti-HEV IgG seroprevalence amongst haemodialysis patients compared to controls (OR = 1.97, 95% CI = 1.16-3.31, P = 0.01) or transplant recipients (OR = 2.63, 95% CI = 1.18-6.07, P = 0.02). Patients with a functioning transplant showed no difference in anti-HEV IgG seroprevalence compared to controls. The duration of haemodialysis or receipt of blood products were not significant risk factors for HEV IgG positivity. Patients receiving haemodialysis have a higher seroprevalence of anti-HEV IgG than both age- and sex-matched controls and a cohort of renal transplant patients. None of the haemodialysis patients had evidence of chronic infection. The reason haemodialysis patients have a high seroprevalence remains uncertain and merits further study.

Factors affecting long-term survival of tunnelled haemodialysis catheters--a prospective audit of 812 tunnelled catheters.

BACKGROUND: In 2001, in the US, 23% of haemodialysis patients were dialysing through tunnelled venous catheters (TVCs), and in the UK (2006) there were 28% of prevalent patients using catheters. It is unlikely that numbers will significantly decrease. We present the results of a prospective audit of the survival of 812 TVCs placed in 492 patients at our institution over a 6-year period (comprising 212 048 patient catheter days or 7068 patient catheter months of follow-up). Four different designs of catheter were studied: Split-Cath III (Medcomp), HemoSplit (Bard), Tesio twin catheter (Medcomp) and Permcath (Quinton). METHODS: We used Kaplan-Meier survival analysis with log-rank test, to compare the effect of different parameters on catheter survival. The relative importance of significant parameters was determined by Cox regression analysis. RESULTS: We have shown a significant catheter survival advantage of first catheters over second and subsequent insertions, of right internal jugular site over left internal jugular and thereafter over femoral site, and of non-diabetic over diabetic patients. Patient age, sex and operator (physician in ward-based procedure room under ultrasound control or surgeon in operating theatre under fluoroscopic assistance) did not significantly affect survival. The Permcath design demonstrated inferior survival in all but first catheter insertions in catheter-naïve patients. The HemoSplit and Tesio twin catheter designs demonstrated best survival overall. By Cox proportional hazard modelling the design and the position of the TVC seemed to be the most significant independent survival factors. CONCLUSIONS: Clinicians need accurate data regarding catheter survival, mode of insertion and design, to inform practice.

Predictors of recurrent hyperparathyroidism after total parathyroidectomy in chronic renal failure.

BACKGROUND/AIMS: Recurrent hyperparathyroidism (HPT) after total parathyroidectomy (TPTX) in chronic renal failure appears more common than might be anticipated. METHODS: To study its predictors, we reviewed all 20 cases of TPTX performed at our hospital in a 10-year period. RESULTS: During follow-up (median 46.8 months (range 9.3-120.3)), 15 patients had measurable PTH levels (>10 pg/ml), 7 had levels above the normal range (recurrent HPT), and 3 had PTH levels >300 pg/ml (severe recurrent HPT). Total follow-up post-TPTX was equal in those who developed recurrent HPT and others, but those with recurrent HPT had spent longer on dialysis post-TPTX (61.9 +/- 34.9 vs. 21.8 +/- 12.0 months; p = 0.001). Patients with recurrent HPT required less vitamin D supplementation during the 10 days post-TPTX (p = 0.025). Log [maximal PTH post-TPTX] correlated with duration of dialysis dependency post-TPTX (r = 0.591, p = 0.006), lowest serum calcium level during the first 30 days post-TPTX (r = 0.449, p = 0.047), and mean serum calcium during the first 30 days post-TPTX (r = 0.546, p = 0.013). Mean log [maximal PTH post-TPTX] was significantly lower in patients with ectopic calcification (p = 0.047). In multiple regression analysis, duration of dialysis post-TPTX and lowest serum calcium level during the first 30 days post-TPTX were the only independent predictors of log [maximal PTH post-TPTX]. CONCLUSION: Recurrent HPT is common following TPTX and predicted by duration of dialysis dependency post-TPTX, a measure of overall exposure to the uraemic stimulus to parathyroid hyperplasia, and the degree of early hypocalcaemia, possibly reflecting the adequacy of operative parathyroid ablation.