A whole system approach to improving mortality associated with acute kidney injury.

BACKGROUND: Acute kidney injury (AKI) is in the main managed by non-nephrologists, many who feel challenged by or lack awareness of the complexity that the renal element adds to their patients' care. National reports have raised major concerns about the quality of care and have predicted that mortality reductions of 30% are achievable with good medical practice. AIM: This quality improvement project evaluated whether a whole system approach could improve outcomes for patients with AKI. DESIGN AND METHODS: Quality improvement methodology was used to understand hospital patterns, processes and professional knowledge. Change concepts were developed which included management of patients at risk, staff education and awareness program, development of a patient specific electronic alert to prompt diagnosis, easy to remember care bundle (ABCDE-IT), dedicated outreach team and patient and family empowerment leaflet. RESULTS: Statistical process control analysis was used to verify outcomes over time. A shift in the in-hospital mortality rate corresponded to a relative 23.2% reduction in mortality and was sustained over the next 33 months (P < 0.0001). The favourable shift in mortality was temporally distinct from the improved AKI detection rate. This timeframe corresponded to lying below the 99.8% lower confidence limit in comparison with all English acute trusts for comparative AKI specific SHMI/HSMR mortality rates. Length of stay also reduced shortly after onset of the project by 14.1% or 2.6 day reduction (P < 0.0001). CONCLUSION: This project demonstrated that an integrated, whole-system approach is necessary to ensure sustained improvements in AKI mortality and length of stay.

Speech disorders in children treated for posterior fossa tumours: ataxic and developmental features.

The oromotor and speech abilities of 19 children (14 boys and five girls) who had been treated for posterior fossa tumour were evaluated using three assessment procedures. All subjects completed the Frenchay Dysarthria Assessment and the Fisher-Logemann Test of Articulation Competence. Perceptual analyses were also performed on the subjects' connected speech samples. Based on the three assessment procedures, 11 of the 19 tumour subjects were judged to be speech disordered. The 11 speech-disordered subjects were then compared to a control group matched for age and sex to determine the nature and severity of speech abnormalities which may occur subsequent to the treatment of posterior fossa tumour in childhood. Both developmental and dysarthric features were identified in the speech of the 11 tumour subjects. The deviant speech characteristics exhibited by the tumour subjects included imprecise consonants, excess stress and reduced intelligibility, as well as the retention of developmental phonological processes. These features are described in detail and discussed with reference to descriptive studies of adult dysarthria. An interaction between acquired and developmental disorders of speech is proposed.