The MOWER (middle of the week everyone gets a re-chart) pilot study: reducing in-hospital charting error with a multi-intervention.

BACKGROUND: Medication charting errors occur often and can be harmful for patients. Interventions to improve charting errors have demonstrated some success particularly if the intervention uses multiple approaches including an education component. The aim of this pilot study was to determine whether a multi-faceted intervention, including education of junior doctors and weekday re-charting could reduce in-hospital charting error. METHODS: Medication charts (n = 579) of all patients admitted to the medical ward of a medium sized regionally-based hospital in Australia over nine months (baseline and during intervention) were inspected for errors. The intervention ran for three months and involved implementation of a National Inpatient Medication Chart targeted error tool with eight targeted charting requirements which was used for visual reminders in the ward and training of junior doctors. In addition, mid-weekly re-charting (MOWER) was performed by a senior and junior doctor team. RESULTS: The mean number of charting requirement errors significantly reduced during the intervention by 26% from 4.6 ± 1.3 to 3.4 ± 1.7 per chart (p < 0.001). Re-chart errors reduced on average by 50% (4.4 ± 1.4 to 2.2 ± 1.7 per chart, p < 0.001) and primary (initial) charts by 20% (4.6 ± 1.3 to 3.7 ± 1.5 per chart, p < 0.001) during the intervention. Failing to provide indication information for a drug, prescriber name, and failing to use generic rather than brand names were the categories with the most errors at baseline and also showed the largest error reductions during the intervention. CONCLUSIONS: A multi-intervention including education of junior doctors, visual reminders and midweek re-charting are effective in reducing the rate of charting errors. We advise that a larger study is now conducted using the same multi-intervention strategy in different ward settings to evaluate feasibility and sustainability of this intervention.

Comparative effects of resistance training on peak isometric torque, muscle hypertrophy, voluntary activation and surface EMG between young and elderly women.

We compared the effect of a 10-week resistance training program on peak isometric torque, muscle hypertrophy, voluntary activation and electromyogram signal amplitude (EMG) of the knee extensors between young and elderly women. Nine young women (YW; range 20-30 years) and eight elderly women (EW; 64-78 years) performed three sets of ten repetitions at 75% 1 repetition maximum for the bilateral leg extension and bilateral leg curl 3 days per week for 10 weeks. Peak isometric torque, EMG and voluntary activation were assessed before, during, and after the training period, while knee extensor lean muscle cross-sectional area (LCSA) and lean muscle volume (LMV) were assessed before and after the training period only. Similar increases in peak isometric torque (16% and 18%), LCSA (13% and 12%), LMV (10% and 9%) and EMG (19% and 21%) were observed between YW and EW, respectively, at the completion of training (P<0.05), while the increase in voluntary activation in YW (1.9%) and EW (2.1%) was not significant (P>0.05). These findings provide evidence to indicate that participation in regular resistance exercise can have significant neuromuscular benefits in women independent of age. The lack of change in voluntary activation following resistance training in both age groups despite the increase in EMG may be related to differences between measurements in their ability to detect resistance training-induced changes in motor unit activity. However, it is possible that neural adaptation did not occur and that the increase in EMG was due to peripheral adaptations.

Contralateral muscle fatigue in human quadriceps muscle: evidence for a centrally mediated fatigue response and cross-over effect.

The purpose of this investigation was to examine the effects of voluntary muscular fatigue in one lower limb and determine whether a 'cross-over' of fatigue is evident in the contralateral limb. Twenty-eight subjects (13 males and 15 females) performed a series of voluntary and evoked isometric contractions of both the dominant (exercised) and non-dominant (non-exercised) leg extensor muscles, prior to and after a fatigue protocol consisting of a 100-s sustained maximal isometric contraction (MVC) performed by the dominant limb only. Force values and surface electromyography (EMG) from the vastus lateralis muscle were obtained allowing for the determination of twitch and compound action potential (M-wave) values. Maximal twitch tension and peak-to-peak amplitude were significantly decreased after the fatigue test in the dominant limb, as was maximal voluntary force (approximately 65 N reduction), EMG activity (approximately 0.1 mV decrease) and voluntary activation (approximately 17% decline). However, no significant changes were observed in the non-dominant limb with respect to twitch and M-wave properties nor in MVC force. The voluntary activation of the non-dominant limb decreased significantly by 8.7% after the fatigue test, which was performed only on the dominant limb. The results of the present study suggest that the decrease in force production in the exercised limb was primarily related to peripheral fatigue mechanisms, with central fatigue making a lesser contribution. Centrally mediated mechanisms appear to be the sole contributor to fatigue in the non-exercised limb suggesting an anticipatory fatigue response and a 'cross-over' of central fatigue between the exercised and non-exercised contralateral limb.

Reduced voluntary activation of human skeletal muscle during shortening and lengthening contractions in whole body hyperthermia.

This study examined the effect of whole body hyperthermia on the voluntary activation of exercised and non-exercised skeletal muscle performing a series of lengthening and shortening contractions. Thirteen subjects exercised on a cycle ergometer at 60% of maximal oxygen consumption until voluntary exhaustion in ambient conditions of approximately 40 degrees C and 60% relative humidity. Before and immediately following the cycle protocol, subjects performed a series of 25 continuous isokinetic shortening and lengthening maximal voluntary contractions (MVCs) of the leg extensors and forearm flexors. Voluntary activation for shortening and lengthening contractions for the forearm and leg was assessed prior to and following the 25 MVCs by superimposing a paired electrical stimulus to the femoral nerve and the biceps brachii during additional MVCs. Exercise to exhaustion increased rectal temperature to 39.35+/-0.50 degrees C. Voluntary activation remained unchanged following the prehyperthermia endurance set of shortening and lengthening maximal contractions in both the forearm flexors and leg extensors. Similarly, voluntary activation remained at prehyperthermic levels for the single MVCs immediately following the cycle trial. However, by the time of completion of the posthyperthermia endurance contractions, voluntary activation had declined significantly by 5.87+/-7.56 and 8.46+/-9.26% in the shortening and lengthening phases, respectively, for the leg extensors but not for the forearm flexors. These results indicate that the central nervous system (CNS) reduces voluntary drive to skeletal muscle performing both shortening and lengthening contractions following exercise-induced hyperthermia. The reductions in voluntary activation were only observed following a series of dynamic movements, indicating that the CNS allows for initial and brief 're-activation' of skeletal muscle following exercise-induced hyperthermia.

Reduced muscle pain intensity rating during repeated cycling trials.

The purpose of this study was to investigate muscle pain intensity rating using a 10-point category-ratio pain intensity scale during self-paced cycling exercise within three trials. Eleven subjects (age 21.4 ± 2.6 years; VO2 peak 3.3 ± 0.9 L·min(-1)) performed a 60-min cycling trial on three occasions. During each trial subjects cycled at the utmost work intensity for 60-min. To simulate competitive training, 1-min maximal effort sprints were performed every 10-mins into the trial. Ambient temperature and relative humidity were set at 33 ± 0.7 (o)C and 63 ± 2.0%, respectively. During exercise, subjects ranked the muscle pain intensity at 5 min intervals and following each sprint effort. Simple main effects revealed that muscle pain intensity ratings were significantly lower in trial 3 compared with trial 1 at the 50 min [F = 4.5(2 30); p = 0.015, eta(2) = 0.05], 55 min [F = 4.89(2, 30); p = 0.011; eta(2) = 0.05], and 60 min [F = 3.6(2, 30); p = 0.034; eta(2) = 0.04] time interval. Repeated measures ANOVA revealed a significant increase in the mean distance cycled amongst the trials (p < 0001). These results indicate an attenuation in muscle pain intensity rating with endurance exercise training when performed over three trials. The reduced pain intensity rating may be due to adjustments in cadence and gear selection amongst the trials. Key PointsMuscle pain intensity rating was significantly reduced with three repeated cycling endurance trials.Attenuation in muscle pain intensity rating appeared at 50, 55, 60 mins into exercise within the third trial.The attenuation in muscle pain intensity with training is apparent despite an increase in cycling distance performance.The decline in muscle pain rating and increased cycling performance may be associated with adjustment in cadence and gear selection amongst the endurance trails.

Exercise heat stress does not reduce central activation to non-exercised human skeletal muscle.

In this study we measured the central activation ratio (CAR) of the leg extensors and the elbow flexor muscles before and after exhaustive exercise in the heat to determine whether exercise-induced hyperthermia affects the CNS drive to exercised (leg extensors) and/or non-exercised (forearm flexors) muscle groups. Thirteen subjects exercised at fixed intensities representative of a percentage of peak power output (PPO) for 10 min periods (50 %, 40 %, 60 %, 50 %) and then at 75 % PPO until exhaustion in ambient conditions of 39.3 +/- 0.8 degrees C and 60.0 +/- 0.8 % relative humidity. Before and immediately following exercise subjects performed a series of maximal voluntary contractions (MVCs) with the leg extensors (exercised muscles) and forearm flexors (non-exercised muscles). The degree of voluntary activation during the sustained MVCs was assessed by superimposing electrical stimulation to the femoral nerve and the biceps brachii. Exercise to exhaustion increased the rectal temperature from 37.2 +/- 0.2 to 38.8 +/- 0.2 degrees C (P < 0.0001). The mean heart rate at the end of exercise to exhaustion was 192 +/- 3 beats min(-1). Leg extensor voluntary force was significantly reduced from 595 +/- 143 to 509 +/- 105 N following exercise-induced hyperthermia but forearm flexor force was similar before and after exercise. The CAR of the leg extensors decreased from 94.2 +/- 1.3 % before exercise to 91.7 +/- 1.5 % (P < 0.02) following exercise-induced hyperthermia. However, the CAR for the forearm flexors remained at similar levels before and after exercise. The data suggest that the central nervous system selectively reduces central activation to specific skeletal muscles as a consequence of exercise-induced hyperthermia.

Glycerol hyperhydration fails to improve endurance performance and thermoregulation in humans in a warm humid environment.

It is equivocal whether glycerol hyperhydration improves exercise performance and thermoregulation in the heat. The purpose of this study was to compare the effectiveness of glycerol with water hyperhydration, using a reliable, self-paced variable-intensity cycling protocol under hot, humid conditions. Seven moderately-to-well trained subjects ingested either a solution consisting of 1.2 g kg(-1) body mass (BM) glycerol mixed with 21 ml kg(-1) BM flavoured water (GLY) or placebo (PL), which was flavoured water of equal volume to the GLY trial, 2.5 h before exercise. Following hyperhydration, subjects undertook a self-paced, variable-intensity cycling protocol designed to simulate racing, with the aim being to cycle as great a distance as possible over 60 min. There were no differences in total distance cycled between conditions (29.7+/-5.7 km for PL, 28.9+/-5.7 km for GLY). Power output was not different at any time between conditions. Terminal rectal temperatures were 39.0+/-0.5 degrees C for PL and 38.8+/-0.7 degrees C for GLY and were not significantly different. Heart rate was significantly higher for GLY only during the high-intensity efforts. The sweat rate for GLY was 1.72+/-0.28 l h(-1) (P<0.01) compared with 1.15+/-0.29 l h(-1) for PL. It is concluded that glycerol hyperhydration has no significant advantage over water hyperhydration on performance or thermoregulation during a 1-h, variable-intensity exercise performance.

Influence of lean body mass on performance differences of male and female distance runners in warm, humid environments.

The purpose of this investigation was to evaluate the influence of lean body mass (LBM) and body weight (BW) on the thermoregulatory responses and endurance performance of male and female athletes in warm, humid environments. Ten (5 males, 5 females) healthy, moderately trained athletes with varying physiques performed a self-paced 30-min run on a motorized treadmill in warm (30 degrees C), humid (60% relative humidity) conditions, with the aim of running the greatest distance possible. Males completed one trial, while females completed two trials, one in each of the follicular (Fol) and luteal (Lut) phases of the menstrual cycle in a randomized fashion. There were no significant differences among groups for distance run (males, 5.2 +/- 0.4 km; Fol, 4.9 +/- 0.1 km; Lut, 4.7 +/- 0.1 km). However, following analysis of covariance accounting for LBM and BW, the distances run were significantly different. The adjusted means for distance run after accounting for LBM were 3.4 km for males (P < 0.05), 5.9 km for Fol, and 5.6 km for Lut. Adjusted means accounting for BW resulted in run distances of 6.5 km for males (P < 0.05), 4.2 km for Fol, and 4.0 km for Lut. Thermoregulatory responses such as rectal and skin temperatures were similar among groups. Avenues of heat loss and gain were altered relative to the menstrual cycle phase. The results suggest that one reason for the disparity in performance between male and female athletes over similar race distances might in part be related to unequal body characteristics and in particular to differences in LBM.