Platelet count and prothrombin time help distinguish thrombotic thrombocytopenic purpura-hemolytic uremic syndrome from disseminated intravascular coagulation in adults.

Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) and disseminated intravascular coagulation (DIC) may have identical manifestations in adults. Because TTP-HUS is 90% fatal without plasma exchange, prompt diagnosis is essential. To test the hypothesis that routine laboratory assays can discriminate between the 2 entities, we retrospectively identified adult patients with TTP-HUS and matched each with 2 patients with DIC. Although the platelet count, prothrombin time (PT), and partial thromboplastin time were different (P < .05) between the 2 patient groups, after regression analysis, only PT and profound thrombocytopenia remained associated with TTP-HUS (P = .001 and P = .003, respectively). A platelet count of less than 20 x 10(3)/microL (20 x 10(9)/L) and a PT within 5 seconds of the upper limit of the reference interval had a specificity of 92% for TTP-HUS. Our data confirm that readily available laboratory assays in the proper clinical scenario can increase the likelihood of TTP-HUS over DIC.

Durable improvements in efficiency, safety, and satisfaction in the operating room.

BACKGROUND: Enhanced productivity and efficiency in the operating room must be balanced with patient safety and staff satisfaction. In December 2004, transition to an expanded replacement hospital resulted in mandatory overtime, unpredictable work hours, and poor morale among operating room (OR) staff. A staff-retention crisis resulted, which threatened the viability of the OR and the institution. We report the changes implemented to efficiently deliver safe patient care in a supportive environment for surgeons and OR staff. STUDY DESIGN: University of Alabama at Birmingham University Hospital OR data were evaluated for fiscal year 2004 and compared with fiscal years 2005 and 2006. Case volumes, number of operational ORs, and on-time case starts were evaluated. OR adverse events were tabulated. Percentage of registered nurse hires and staff departures served as a proxy for staff satisfaction. RESULTS: Short, intermediate, and longterm strategies were implemented by an engaged OR management committee with the guidance of surgical, anesthesia, and hospital leadership. These included new block time release policies; use of traveling nurses until new staff could be hired and trained; and incentive-based, voluntary, employee-scheduled overtime. Mandatory nursing education time was blocked weekly. Enforcement of the National Patient Safety Goals were implemented and adjudicated with a "surgeon-of-the-day" system providing backup for nurse management. We demonstrated an increase in operations per year, on-time starts, and registered nurse hires in fiscal years 2005 and 2006. During this same time, we were able to markedly decrease the number of adverse events, admitting delays, and staff departures. CONCLUSIONS: Change is difficult to accept but essential when vital clinical activities are impaired and at risk. To maintain important clinical environments like the OR in an academic center, we developed and implemented effective, data-driven changes. This allowed us to retain critical human resources and restore a supportive environment for the patients, the doctors, and the staff.