Prospective Evaluation of Outpatient Flexible Sigmoidoscopy in Patients With Deep Infiltrating Endometriosis.

INTRODUCTION: To study patients' acceptability of an outpatient flexible sigmoidoscopy (FS) protocol and to assess the diagnostic value of endoscopic assessment in patients with deep endometriosis (DE). METHODS: All patients with DE and suspected bowel involvement diagnosed were reviewed in the colorectal outpatient clinic before elective surgery following multidisciplinary team meeting discussion. Patients were consented for having the FS performed at the same time of the clinical consultation. Primary outcome was diagnostic value of the FS. RESULTS: Sixty patients were included. Fifty-eight (96.7%) patients consented for the outpatient FS, demonstrating a high rate of patients' acceptability. The sigmoidoscopy demonstrated no abnormalities in 48 patients (82.7%), diverticulosis in 5 patients (8.6%), polyps in 2 patients (3.4%) and mucosal endometriosis in 1 patient only (1.7%). CONCLUSIONS: Outpatient FS during the preoperative consultation with the colorectal surgeon is feasible in patients with DE affecting the bowel with a high rate of patients' acceptability but limited additional diagnostic value.

Improved Safety Culture and Teamwork Climate Are Associated With Decreases in Patient Harm and Hospital Mortality Across a Hospital System.

OBJECTIVES: Improved safety and teamwork culture has been associated with decreased patient harm within specific units in hospitals or hospital groups. Most studies have focused on a specific harm type. This study's objective was to document such an association across an entire hospital system and across multiple harm types. METHODS: The Safety Attitudes Questionnaire (SAQ) was administered to all clinical personnel (including physicians) before, 2 years after, and 4 years after establishing a comprehensive patient safety/high-reliability program at a major children's hospital. Resultant data were analyzed hospital-wide as well as by individual units, medical sections, and professional groups. RESULTS: Safety attitude scores improved over the 3 surveys (P < 0.05) as did teamwork attitude scores (P = nonsignificant). These increases were accompanied by contemporaneous statistically significant decreases in all-hospital harm (P < 0.01), serious safety events (P < 0.001), and severity-adjusted hospital mortality (P < 0.001). Differences were noted between physicians' and nurses' views on specific safety and teamwork items within individual units, with nursing scores often lower. These discipline-specific differences decreased with time. CONCLUSIONS: Improved safety and teamwork climate as measured by SAQ are associated with decreased patient harm and severity-adjusted mortality. Discrepancies in SAQ scores exist between different professional groups but decreased over time.

A 5-year experience of the changing management of ectopic pregnancy.

This retrospective audit reviewed all ectopic pregnancies over a 5-year period in a district general hospital setting. Of 215 ectopic pregnancies identified, notes were available for 208 (97%). 202 cases were determined to have been diagnosed and managed as ectopic pregnancies. Six cases were excluded as they were pregnancies of unknown location managed as such. The proportion of patients managed non-surgically has increased following the introduction of our consultant-led early pregnancy assessment unit from 25% prior to 31% currently. The success rates have improved in both those managed expectantly (50%-73%) and those with methotrexate (75%-90%). There has been a corresponding drop in those managed surgically from 75% to 69%, and a reduction in negative laparoscopies from 13% to 6%. Provided recommended criteria and follow-up are adhered to, non-surgical management has been shown to have comparative safety to traditional surgical management with acceptable efficacy and patient acceptability.

Optimising the diagnosis of ectopic pregnancy.

This retrospective cohort study reviewed the diagnosis of all ectopic pregnancies within a district general hospital over a 5-year period after the establishment of a dedicated Early Pregnancy Assessment Unit (EPAU). Of 215 ectopic pregnancies identified, notes were available for 208 (97%). Two-hundred and two cases were determined to have been diagnosed and managed as ectopic pregnancies. Six cases were excluded as they were pregnancies of unknown location managed as such. Overall, 91% were diagnosed by ultrasound scan, 5% were diagnosed clinically and 3% were diagnosed on serial human chorionic gonadotrophin (hCG) levels. This study found that the introduction of a dedicated, multi-professional, EPAU with a stable workforce improved ultrasound visualisation of ectopic pregnancies at first ultrasound scan from 22% prior to its commencement, to 61% over this period. The improvement in positive scan diagnosis of ectopic pregnancy was associated with a reduction in negative laparoscopy rate from 13% to 6%.

A patient/family-centered strategic plan can drive significant improvement.

The use of a PFCSP, as a road map to operationalize the hospital's vision, has been a compelling paradigm to achieve significant QI results. The framework is simple yet directly aligns with the IOM domains of quality. It has inspired and helped actively engage hospital personnel in the work required to achieve the goals and vision of the hospital system. Five years after initiating this type of plan, activity is flourishing in each of the domains and midterm results are substantial. We think that the nature of this strategic plan has been an important aspect of our success to date.

A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality.

OBJECTIVE: To evaluate the effectiveness of a hospital-wide initiative to improve patient safety by implementing high-reliability practices as part of a quality improvement (QI) program aimed at reducing all preventable harm. STUDY DESIGN: A hospital wide quasi-experimental time series QI initiative using high-reliability concepts, microsystem-based multidisciplinary teams, and QI science tools to reduce hospital acquired harm was implemented. Extensive error prevention training was provided for all employees. Change concepts were enacted using the Institute for Healthcare Improvement's Model for Improvement. Compliance with change packages was measured. RESULTS: Between 2010 and 2012, the serious safety event rate decreased from 1.15 events to 0.19 event per 10 000 adjusted hospital-days, an 83.3% reduction (P < .001). Preventable harm events decreased by 53%, from a quarterly peak of 150 in the first quarter of 2010 to 71 in the fourth quarter of 2012 (P < .01). Observed hospital mortality decreased from 1.0% to 0.75% (P < .001), although severity-adjusted expected mortality actually increased slightly, and estimated harm-related hospital costs decreased by 22.0%. Hospital-wide safety climate scores increased significantly. CONCLUSION: Substantial reductions in serious safety event rate, preventable harm, hospital mortality, and cost were seen after implementation of our multifaceted approach. Measurable improvements in the safety culture were noted as well.

A double-blind, randomized, controlled trial of tongue-tie division and its immediate effect on breastfeeding.

AIM: This study investigated if a maternally reported, immediate improvement in breastfeeding following division of tongue-tie is due to a placebo effect. METHODS: This randomized controlled trial was conducted at Southampton General Hospital, Southampton, UK, in 2003-2004. Sixty breastfed babies 5-115 days old (mean, 32 days; median, 23 days) were randomized to division (Group A) or non-division (Group B). The mother and a trained observer were blinded and assessed breastfeeding before the intervention. Fifty-seven babies were analyzed because blinding failed in three of the babies in Group A. Following the intervention, the mother's and observer's views were noted, and then those infants allocated to non-division had their tongue-tie divided. RESULTS: Seventy-eight percent (21 of 27) of mothers in Group A reported an immediate improvement in feeding following the intervention, compared with 47% (14 of 30) in Group B (two-tailed χ(2) p<0.02; 95% confidence interval, 6-51%). At 1-day follow-up, 90% (54 of 60) reported improved feeding following division. At 3-month follow-up, 92% (54 of 59) still reported improved feeding, with 51% (30 of 59) continuing to breastfeed. CONCLUSIONS: There is a real, immediate improvement in breastfeeding, detectable by the mother, which is sustained and does not appear to be due to a placebo effect.