Strengthening leadership as a catalyst for enhanced patient safety culture: a repeated cross-sectional experimental study.

OBJECTIVES: Current literature emphasises that clinical leaders are in a position to enable a culture of safety, and that the safety culture is a performance mediator with the potential to influence patient outcomes. This paper aims to investigate staff's perceptions of patient safety culture in a Danish psychiatric department before and after a leadership intervention. METHODS: A repeated cross-sectional experimental study by design was applied. In 2 surveys, healthcare staff were asked about their perceptions of the patient safety culture using the 7 patient safety culture dimensions in the Safety Attitudes Questionnaire. To broaden knowledge and strengthen leadership skills, a multicomponent programme consisting of academic input, exercises, reflections and discussions, networking, and action learning was implemented among the clinical area level leaders. RESULTS: In total, 358 and 325 staff members participated before and after the intervention, respectively. 19 of the staff members were clinical area level leaders. In both surveys, the response rate was >75%. The proportion of frontline staff with positive attitudes improved by ≥5% for 5 of the 7 patient safety culture dimensions over time. 6 patient safety culture dimensions became more positive (increase in mean) (p<0.05). Frontline staff became more positive on all dimensions except stress recognition (p<0.05). For the leaders, the opposite was the case (p<0.05). Staff leaving the department after the first measurement had rated job satisfaction lower than the staff staying on (p<0.05). CONCLUSIONS: The improvements documented in the patient safety culture are remarkable, and imply that strengthening the leadership can act as a significant catalyst for patient safety culture improvement. Further studies using a longitudinal study design are recommended to investigate the mechanism behind leadership's influence on patient safety culture, sustainability of improvements over time, and the association of change in the patient safety culture measures with change in psychiatric patient safety outcomes.

Concomitant one-stage unifocalization and bidirectional Glenn procedure.

A concomitant one-stage unifocalization and bidirectional Glenn procedure was performed in a patient with a functionally single ventricle, pulmonary atresia, and major aortopulmonary collateral arteries (MAPCAs). Reconstruction of the absent central pulmonary artery was achieved using the MAPCAs as well as the autologous pericardium. After 1 year, cineangiography and cardiac catheterization showed an excellent result: well-developed pulmonary arteries as well as low pressure in the superior vena cava. To the best of our knowledge, this is the first report of a successful concomitant one-stage unifocalization and bidirectional Glenn procedure.

Failure of the Amplatzer ductal occluder II: kinking of the aortic retention disk at 24 hours.

Since March 2008, the new Amplatzer duct occluder II (ADO II) has been used clinically for PDA closure in Europe. We report an interesting case of a 2(1/2)-year-old girl with a 3-mm conical shape PDA (type A PDA) who underwent uneventful implantation of 3/4 ADO II with complete closure by angiography and echocardiographic control at the end of the procedure. To our surprise, echocardiography 24 hr later revealed a moderate secondary shunt due to kinking of the aortic retention disk of the device with the central waist and the pulmonary retention disk still in correct position. The persistent shunt was closed 1 year later in the cath lab with a 9/6 Nit-Occlud device. To our knowledge, this is the first reported late complication directly related to the device.

Comparison of electrical velocimetry and transpulmonary thermodilution for measuring cardiac output in piglets.

BACKGROUND: Monitoring of cardiovascular function is essential during major pediatric and pediatric cardiac surgery. Invasive monitoring of cardiac output (CO) and oxygen delivery is expensive and sometimes associated with adverse events. Therefore, we investigated the accuracy of a new noninvasive CO monitoring device using electrical velocimetry (EV) in comparison with the more invasive transpulmonary thermodilution (TPTD) method. METHODS: In five fasted, anesthetized and mechanically ventilated piglets, CO was measured simultaneously using EV and TPTD under normal conditions, volume loading, inotropic support and exsanguination. RESULTS: In five piglets, 169 measurements could be performed. The correlations between EV-CO and TPTD-CO were significant for absolute values (P < 0.0001, r = 0.82) and relative changes from baseline (P < 0.0001, r = 0.93). The receiver operating characteristic (ROC) curve analysis of the relative changes of the EV-CO values in relation to the first EV-CO measurement showed a sensitivity of 91% and specificity of 94% (AUC 0.974, 95% CI 0.96-0.99). Changes in TPTD-CO greater than 15% lead to a change of EV-CO in the same direction in 93%. Bland-Altman analysis showed a mean difference between the two methods of -0.63 l x min(-1) with an sd of 0.64 l x min(-1). The lower and upper limits of agreement were -1.88 and 0.62 l x min(-1), percentage limit of agreement was +/-82.8%. CONCLUSIONS: The results show that EV is a safe, simple, noninvasive and cost-effective method for continuous trend monitoring of CO in piglets. The agreement of the EV-CO with TPTD-CO is not good enough to replace the standard method in our animal model. A correction factor for body habitus in piglets may be beneficial.

Correlation of oxygen delivery with central venous oxygen saturation, mean arterial pressure and heart rate in piglets.

BACKGROUND: Accurate assessment and monitoring of the cardiocirculatory function is essential during major pediatric and pediatric cardiac surgery. Invasive monitoring of cardiac output and oxygen delivery (DO(2)) is expensive and sometimes associated with adverse events. Measurement of central venous oxygen saturation (ScvO(2)) is less invasive and may reflect the DO(2). Therefore, we investigated the correlation of ScvO(2) with cardiac index (CI) and DO(2) and in comparison the more common monitored parameters heart rate (HR) and mean arterial pressure (MAP) with DO(2) in an animal experimental setting. METHODS: In five fasted, anesthetized and mechanically ventilated piglets CI (transpulmonary thermodilution), venous and arterial blood gases, HR and MAP was measured during normal conditions, volume loading, inotropic support, and exsanguination. RESULTS: In the five piglets 168 measurements could be performed. In a wide hemodynamic range (CI 22-335 ml x kg(-1) min(-1)) we found significant correlations of ScvO(2) with DO(2)) (r(2) = 0.91, P < 0.0001) and CI (r(2) = 0.88, P < 0.0001) and also between DO(2) and MAP (r = 0.86, P < 0.0001) and HR (r = 0.19, P < 0.05). CONCLUSIONS: ScvO(2) is a better parameter for indirect estimation of DO(2) than MAP and heart rate. Measurement of ScvO(2) is simple and does not necessitate additional invasive techniques. In the clinical setting ScvO(2) should be used in combination with other standard vital parameters, i.e. MAP, central venous pressure, lactate, base excess, and urine output.

Detection and analysis of enzymatic DNA methylation of oligonucleotide substrates by matrix-assisted laser desorption ionization time-of-flight mass spectrometry.

Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF) mass spectrometry was employed to analyze DNA methylation carried out by the Escherichia coli dam DNA methyltransferase using oligonucleotide substrates with molecular masses of 5000-10,000 Da per strand. The mass spectrometry assay offers several advantages: (i) it directly shows the methylation as the increase in the mass of the substrate DNA, (ii) it is nonradioactive, (iii) it is quantitative, and (iv) it can be automated for high-throughput applications. Since unmethylated and methylated DNA are detected, the ratio of methylation can be determined directly and accurately. Furthermore, the assay allows detection individually of the methylation of several substrates in competition, offering an ideal setup to analyze the specificity of DNA interacting with enzymes. We could not identify methylation at any noncanonical site, indicating that the dam MTase is a very specific enzyme. Finally, MALDI-TOF mass spectrometry permitted assessment of the number of methyl groups incorporated into each DNA strand, thereby, allowing study of mechanistic details such as the processivity of the methylation reaction. We provide evidence that the dam MTase modifies DNA in a processive reaction, confirming earlier findings.

Probing the DNA interface of the EcoRV DNA-(adenine-N6)-methyltransferase by site-directed mutagenesis, fluorescence spectroscopy, and UV cross-linking.

The EcoRV DNA-(adenine-N6)-methyltransferase recognizes GATATC sites and methylates the DNA as indicated. It is related to the large family of dam methyltransferases which modify GATC sites. We have studied the interaction of DNA with M.EcoRV and 12 M.EcoRV variants using oligonucleotides containing 2-aminopurine as a fluorescence probe in equilibrium and stopped-flow DNA binding studies and 5-iododeoxyuracil for UV cross-linking. M.EcoRV binds to DNA in a multistep binding reaction, including two different conformations of the specific enzyme-DNA complex, and induces a strong conformational change of the DNA at the fourth position of the recognition site. Mutations at residues forming contacts to the GAT part of the recognition site reduce the stability of both specific enzyme-DNA complexes. Two enzyme variants which fail to recognize the ATC part do not induce the deformation of the DNA which explains why they cannot interact properly with the recognition site. Other mutations at residues which interact with the ATC part selectively reduce the stability of the second enzyme-DNA complex. These results show that when approaching the DNA M.EcoRV first contacts the GAT part of the target site. Since the residues mediating these contacts are conserved among M.EcoRV and dam MTases, the kinetics of formation of the enzyme-DNA complex correspond to the evolutionary history of the protein. Whether the observation that evolutionarily conserved contacts are formed early during complex formation is a general rule for DNA interacting enzymes or proteins that change their specificity during evolution remains to be seen.

The Escherichia coli dam DNA methyltransferase modifies DNA in a highly processive reaction.

The Escherichia coli dam adenine-N6 methyltransferase modifies DNA at GATC sequences. It is involved in post-replicative mismatch repair, control of DNA replication and gene regulation. We show that E. coli dam acts as a functional monomer and methylates only one strand of the DNA in each binding event. The preferred way of ternary complex assembly is that the enzyme first binds to DNA and then to S-adenosylmethionine. The enzyme methylates an oligonucleotide containing two dam sites and a 879 bp PCR product with four sites in a fully processive reaction. On lambda-DNA comprising 48,502 bp and 116 dam sites, E. coli dam scans 3000 dam sites per binding event in a random walk, that on average leads to a processive methylation of 55 sites. Processive methylation of DNA considerably accelerates DNA methylation. The highly processive mechanism of E. coli dam could explain why small amounts of E. coli dam are able to maintain the methylation state of dam sites during DNA replication. Furthermore, our data support the general rule that solitary DNA methyltransferase modify DNA processively whereas methyltransferases belonging to a restriction-modification system show a distributive mechanism, because processive methylation of DNA would interfere with the biological function of restriction-modification systems.