The handover room: a qualitative enquiry into the experience of morning clinical handover for acute medical teams.

BACKGROUND: Effective clinical handover has always been integral to delivering safe, high-quality care in medical wards. AIM: As handover activity increases in importance we wanted to explore the experience of physicians and trainee doctors. There is little research on internal medicine handover with even less based on direct observational research. METHODS: Data collection over 4 months by two general medicine physicians included participant observation of 37 meetings and 52 audio-recorded individual interviews. Inductive thematic analysis of the transcribed interviews proceeded iteratively in parallel with data collection. RESULTS: There was an excellent response rate from 27 of 28 invited trainees and 25 of 26 invited physicians. Overall the experience was positive. Acute medicine handover is a complex human endeavour, occurring daily with an unpredictable workload and areas of tension. Themes were grouped as structural (leadership role, start time, sequence, checklist, handbacks and efficiency) and relational (sensitivity, collegiality, acknowledgement, performance anxiety, tension, responsibility and leadership style). The physician leader needs to be skilled to follow the agreed and evolving process as well as being prepared, authoritative, flexible, equitable, aware and sensitive to the needs of senior colleagues and trainees. There was a tension between efficiency and teaching opportunities. CONCLUSION: This paper adds to a contextually sensitive understanding of the social dynamics of handover in acute medicine. Addressing the structural aspects is important to provide the necessary consistency and efficiency in what is an extremely complex and time-sensitive environment. As we continue to work on the evolution of the handover process in acute internal medicine, we must also attend to the relational aspects which are dynamic and central to its sustainability.

Bacterial contamination of platelet concentrates produced in New Zealand.

AIMS: To identify the rate of bacterial contamination of platelet concentrates in New Zealand and compare with other countries who use the BacT/ALERT screening system. To report on septic transfusion reactions associated with platelet transfusion in New Zealand. METHODS: Six mL of platelet concentrate is inoculated into a BacT/ALERT BPA (aerobic culture) bottle on Day 2 post-collection. Bottles that are flagged as positive are sent to the microbiology laboratory, with the associated unit, for confirmatory testing. Platelet units that have expired are sampled again. Results from the four blood processing sites in New Zealand were reviewed. RESULTS: 59,461 (65%) platelet components were sampled on Day 2 and 15,560 (17%) were re-sampled post-expiry, between December 2003 and September 2011. The rate of confirmed bacterial contamination was 0.04% for Day 2 sampling and 0.04% for post-expiry sampling. The rate in the published literature ranges from 0.01-0.74% and is lower (0.01-0.18%) when diversion of the initial flow of blood is utilised. There were five bacterial transfusion transmitted infections associated with platelet transfusion reported during the study period. CONCLUSIONS: BacT/ALERT screening reduces the transfusion of bacterially contaminated platelet concentrates. Day 2 sampling does not identify all contaminated units.

Transfusion-related acute lung injury (TRALI): a review of investigations by the National Tissue Typing Laboratory of cases reported in New Zealand since June 2004.

AIM: To review investigations of reported cases of Transfusion-Related Acute Lung Injury (TRALI) performed by the National Tissue Typing laboratory since 2004. METHOD: Donors associated with reported cases of TRALI are recalled for white cell antibody tests. A donor is implicated if found to have neutrophil or HLA antibodies with specificity against one of the recipient's HLA antigens, or a positive white cell crossmatch. A retrospective review of investigations performed by the Tissue Typing Laboratory on TRALI cases from June 2004 to June 2007 was undertaken. RESULTS: Seventeen cases of TRALI had tests performed by the Tissue Typing Laboratory over the 3-year period. A total of 67 donors were tested. Twenty-nine donors had a positive HLA-antibody screen and the majority of these were female (86%, with fresh frozen plasma (FFP) the commonest component type (41%). In 15 (88%) cases, HLA antibodies were found in donor sera and nine of these had specificity against patient HLA antigen or a positive crossmatch. CONCLUSION: Preliminary data on TRALI investigations concur with overseas studies. Raising awareness of this hazard of transfusion and a consistent approach in investigation of TRALI will allow us to gain further insight into this complication in New Zealand and consequently explore strategies to prevent such adverse transfusion reactions.

Review of positive direct antiglobulin tests found on cord blood sampling.

UNLABELLED: Until recently, all babies born in Wellington had umbilical cord blood sampling for direct antiglobulin test (DAT). It is considered to be an important test in identifying babies who are at risk of haemolytic disease of the newborn (HDN). OBJECTIVE: The aim of this review was to examine the utility of positive DAT results and ascertain: -- How many cases required phototherapy? -- Were any babies readmitted for phototherapy? -- Did the positive DAT influence the detection and treatment of HDN? METHODS: The clinical records of all newborn babies found to have positive DATs by Wellington Hospital Blood Bank, over a 6-month period (January 2001-June 2001) were reviewed. Blood group serological results of all babies that received phototherapy during this period were also reviewed. RESULTS: Ninety-four babies had a positive DAT, of which 22 (23%) received phototherapy. The incidence of a positive cord blood DAT was found to be 5.5%. In total, 1724 cord blood samples were analysed by Blood Bank over the first 6 months in 2001. Overall 145 babies received phototherapy, 117 were DAT-negative and six were not tested. Six of the 22 (27%) DAT-positive babies that received phototherapy were alerted by a positive DAT, leading to measurement of serum bilirubin (SBR). Twelve of the 22 (55%) were initially alerted by clinical jaundice, leading to measurement of SBR. Two DAT-positive cases were diagnosed antenatally, both were due to anti-D. Overall 10 babies were readmitted for phototherapy, two had a positive DAT. One baby received an exchange transfusion in addition to phototherapy. Two babies that received phototherapy had SBRs in the exchange transfusion range. Eighty-six per cent of the DAT-positive cases treated with phototherapy were due to anti-A. There were four cases of DAT-negative ABO HDN. CONCLUSIONS: The positive predictive value of a positive DAT for HDN is 23%. The sensitivity was estimated to be 86%. Ten babies required readmission for phototherapy, two of these were DAT-positive. Jaundice, rather than the positive DAT, was the first alert in the majority of cases of HDN requiring phototherapy. Recommendations for testing are discussed but remain controversial in practice. Assessment for hyperbilirubinaemia in all infants early in life is fundamental.