'Every patient, every day': a daily ward round tool to improve patient safety and experience.

INTRODUCTION: Many essential interventions are required to ensure in-patients receive safe and effective care with a good experience. In addition, healthcare organisations are assessed on numerous performance indicators, including the aforementioned interventions, where underperformance can lead to lower publicly reported ratings, loss of income and reputational damage. Most importantly, underperformance can lead to compromised patient experience and outcomes. We created a prompt card as a service improvement tool to be used on the daily ward rounds at the bedside of every patient, entitled 'every patient, every day' to improve documentation, antibiotic prescribing, venous thromboembolism (VTE) prophylaxis, coding and patient communication. METHOD: Preimplementation data around these interventions and patient experience factors were collected by shadowing ward rounds. The 'every patient, every day' tool was then implemented. The ward rounds were shadowed by the same individual to collect post-implementation data. Effect of implementation was assessed via Poisson regression models conducted on the documentation, antibiotics and VTE measures, and logistic regression models conducted on the communication and coding measures. RESULTS: The corresponding rate ratios for the effect of the implementation of the service improvement tool were found to be 1.53 (95% CI 1.38 to 1.69) for improved documentation. Antibiotics prescribing improved by 1.44 (95% CI 1.06 to 1.94). VTE prescribing and documentation improved by a rate ratio 1.25 (95% 1.04 to 1.50). For communication, the effect of the implementation was significant at the 5% significance level (p<0.001), with an OR of 18.6 (95% CI 8.41 to 41.09). Coding effect was non-significant at the 5% significance level (p=0.113) but was substantive. Implementation of the tool resulted in substantive improvements in all outcomes and shows corrected significance with the documentation and communication outcomes. CONCLUSION: The 'every patient, every day' ward round prompt card is an extraordinarily simple tool shown to increase compliance with a number of safety and quality indicators to improve an organisation's performance, and hopefully be a facet contributing to enhanced patient experience and outcomes.

Use of Omniflow® II in Infected Vascular Grafts with Femoral Anastomotic Dehiscence.

BACKGROUND: Vascular graft infection with anastomotic dehiscence requires immediate surgical intervention to preserve life and limb. We present our experience of using the Omniflow® II biosynthetic vascular prosthesis (LeMaitre Vascular) in the emergency repair of vascular graft dehiscence at the femoral anastomosis. METHODS: A retrospective review of consecutive patients presenting with femoral anastomotic dehiscence in a single centre was conducted. All patients were revascularized using an in situ Omniflow II graft. Patient demographics, affected graft type, microbiology, and antibiotic regimes were documented. Primary outcome measures were limb salvage, patency rates, and mortality. RESULTS: Five patients presented with acute femoral false aneurysm and four of five with significant hemorrhage. Infected grafts included one aortobifemoral, two femoral crossover, one axillobifemoral, and one infrainguinal reversed vein graft. All were revascularized with an in situ Omniflow II graft following the excision of the infected graft material. The median followup was 50 months. Limb salvage was achieved in 8 of 9 threatened limbs, and none required further intervention for re-infection. One graft occluded at 5 months. Two of five patients died during followup (one at 12 months, one at 50 months). CONCLUSIONS: Omniflow II provides a useful "off-the-shelf" conduit for the urgent revascularization of infected femoral dehiscence.

Attitudes towards the surgical safety checklist and factors associated with its use: A global survey of frontline medical professionals.

BACKGROUND: The Surgical Safety Checklist (SSC) has been shown to reduce perioperative errors and complications and its implementation is recommended by the World Health Organisation (WHO). However, it is unknown how widely this intervention is used. We investigated attitudes and factors associated with use of WHO SSC in frontline medical professionals across the globe using a survey distributed through social networks. METHODS: A survey of usage and opinions regarding the SSC was posted on the Facebook and Twitter pages of a not-for-profit surgical news website for one month (March 2013). Respondents were grouped into four groups based on their country's Gross National Income: high, upper middle, lower middle and low income. Univariate and multivariate analyses were performed to investigate how different factors were associated with the use of the SSC. RESULTS: 6269 medical professionals from 69 countries responded to the survey: most respondents were from lower middle (47.4%) countries, followed by: high (35.0%), upper middle (14.6%), and low (3.0%) income countries. In total, 57.5% reported that they used the WHO SSC perioperatively. Fewer respondents used the WHO SSC in upper middle, lower middle and low income countries (LMICs) compared to high income countries (43.5% vs. 83.5%, p < 0.001). Female (61.3% vs. 56.4% males, p = 0.001), consultant surgeons (59.6% vs. 53.2% interns, p < 0.001) and working in university hospitals (61.4% vs. 53.7% non-university hospitals, p < 0.001) were more likely to use the SSC. Believing the SSC was useful, did not work or caused delays was independently associated with the respondents reported use of the SSC (OR 1.22 95% CI 1.07-1.39; OR 0.47 95% CI 0.36-0.60; OR 0.64 95% CI 0.53-0.77, respectively). CONCLUSION: This study suggests the use of the WHO SSC is variable across countries, especially in LMICs where it has the most potential to improve patient safety. Critical appraisal of the documented benefits of the WHO SSC may improve its adoption by those not currently using it.

Altered fibrin clot structure and function in the healthy first-degree relatives of subjects with intermittent claudication.

OBJECTIVE: Studies report clustering of cardiovascular risk factors and increased cardiovascular events in healthy first-degree relatives (FDR) of subjects with intermittent claudication (IC). Family history is an independent risk factor in coronary artery disease but the role of genetic factors is undefined in peripheral arterial disease. The fibrin clot is the final product of the atherothrombotic process and is subject to genetic influence. We proposed that healthy male FDR of subjects with IC possess abnormalities in their fibrin clots. METHODS: This was a case-control family study. The FDR were recruited from claudicants attending vascular surgery out-patient clinics with the control subjects being recruited from the local primary care register. A total of 106 white European male FDR of male subjects with IC were age matched with 107 white European male control subjects from an identical geographic area. The control subjects had no FDR with a history of symptomatic cardiovascular disease, and subjects from both groups were free from a personal history of symptomatic cardiovascular disease or diabetes mellitus. Ex vivo assays for fibrin clot permeation, fiber thickness, factor XIII cross-linking activity, and fibrinolysis were performed on the plasma of the above subjects. In addition, linear regression analysis was undertaken to determine factors associated with clot parameters. RESULTS: For controls and FDR, respectively, fiber thickness by turbidity was 0.75 (0.67-0.93) vs 0.86 (0.75-0.98) (P < .001), and FXIII cross-linking activity was 105% (87-141) vs 133% (103-155) (P < .001). On confocal microscopy, fibers measured 315.8 (307.0-324.6) vs 405.1 (397.6-412.6) nm (P < .001), and lysis front velocity was 12.66 (6.38-18.94) vs 4.83 (2.50-7.17), mum/min (P = .018). Linear regression analysis revealed cholesterol was associated with changes in certain clot parameters. CONCLUSION: The healthy FDR of subjects with IC produce clots which have thicker fibers, increased cross-linking, and resistance to fibrinolysis when compared to controls. This supports the potential genetic basis of peripheral arterial disease and highlights that cholesterol may contribute to this abnormal structure. This suggests that the FDR of subjects with IC, an apparently healthy sub-group of the population, have an elevated cardiovascular risk associated with abnormalities in their clot structure.