A 7-day team-based model of care in general medicine: implementation and outcomes at 12 months.

BACKGROUND: Demand for inpatient beds is increasing whilst supply is diminishing. General medical services are feeling this demand as the ageing population presents more patients with undifferentiated illness traditionally cared for by this service. Redesign efforts need to focus on improving the quality and speed of decision-making to utilise resources efficiently. AIMS: The aim of this study was to improve patient flow through general medical services by undertaking a comprehensive redesign process targeting each stage of the patient journey. METHODS: We utilised a rapid improvement event to identify waste and design a new model of care (MOC) that eliminated as much waste as possible. The model had three main elements: (i) ward-based teams; (ii) 7-day per week standard work; and (iii) pull systems to operate for all transfers and referrals. Here, we analyse the first 12 months of the new MOC with regard to key outcomes: length of stay, occupancy, weekend discharges, clinical incidents and Medical Emergency Team (MET) calls, emergency department length of stay and National Emergency Access Target (NEAT) performance and elective surgical throughput. RESULTS: The new MOC resulted in a 0.88-day reduction in length of stay. This resulted in reduced general medical bed occupancy of 19 beds. Weekend discharges improved by 54.6%. There were no significant increases in serious clinical incidents or MET calls. Emergency department admitted NEAT performance improved also. CONCLUSION: Redesign of the general medicine model of care eliminating waste has resulted in a significant improvement in patient flow and reduced length of stay without compromising quality of care.

Review of medical discharge summaries and medical documentation in a metropolitan hospital: impact on diagnostic-related groups and Weighted Inlier Equivalent Separation.

BACKGROUND: Accurate and comprehensive clinical documentation is crucial for effective ongoing patient care, follow up and to optimise case mix-based funding. Each Diagnostic Related Group (DRG) is assigned a 'weight', leading to Weighted Inlier Equivalent Separation (WIES), a system many public and private hospitals in Australia subscribe to. AIMS: To identify the top DRG in a general medical inpatient service, the completeness of medical discharge documentation, commonly missed comorbidities and system-related issues and subsequent impact on DRG and WIES allocation. METHODS: One hundred and fifty completed discharge summaries were randomly selected from the top 10 medical DRG in our health service. From a detailed review of the clinical documentation, principal diagnoses, associated comorbidities and complications, where appropriate, the DRG and WIES were modified. RESULTS: Seventy-two (48%) of the 150 reviewed admissions resulted in a revision of DRG and WIES equivalent to an increase of AUD 142,000. Respiratory-based DRG generated the largest revision of DRG and WIES, while 'Cellulitis' DRG had the largest relative change. Twenty-seven per cent of summaries reviewed necessitated a change in coding with no subsequent change in DRG allocation or WIES. Acute renal failure, anaemia and electrolyte disturbances were the most commonly underrepresented entities in clinical discharge documentation. Seven patients had their WIES downgraded. CONCLUSION: Comprehensive documentation of principal diagnosis/diagnoses, comorbidities and their complications is imperative to optimal DRG and WIES allocation. Regular meetings between clinical and coding staff improve the quality and timeliness of medical documentation, ensure adequate communication with general practitioners and lead to appropriate funding.

Dapsone-associated methaemoglobinaemia in patients with a haematologic malignancy.

Methaemoglobinaemia is an uncommon problem which can significantly impact on oxygen carriage and may necessitate intensive care management. The occurrence of symptomatic methaemoglobinaemia over a three-month period in four patients with haematological malignancies on dapsone for Pneumocystis jiroveci pneumonia prophylaxis prompted a review of its use in this group of patients. We performed a retrospective audit to identify any contributing factors. Co-oximetry was employed to identify patients with methaemoglobinaemia. Thirty-four patients with haematological malignancies received dapsone between January and December 2008, of whom 53% (n = 18) had co-oximetry studies done. Raised methaemoglobin levels (> or = 1.5%) were seen in 13 patients, four of them symptomatic. Mean peak level was of 7.84% (range 1.9 to 26.8%). Eight patients required intensive care support. Mean onset of methaemoglobinaemia was 11.8 days (range 4 to 18 days) following dapsone commencement. All patients were anaemic with an average haemoglobin of 85.5 g/l (range 59 to 111 g/l). All patients were prescribed 'azole' antifungal agents and five patients were also on high-dose steroids, both agents known to induce cytochrome P-450 enzymes and hence potentiating dapsone toxicity. Our experience suggests that dapsone should be used with caution in patients with haematological malignancies as they are particularly at risk of developing symptomatic methaemoglobinaemia due to underlying anaemia, immunosuppression and potential drug interactions. The current recommendation of dapsone for Pneumocystis jiroveci pneumonia prophylaxis in this group of patients needs to be reviewed. When methaemoglobinaemia does occur early recognition is possible with routine co-oximetry testing and prompt treatment may lessen the need for or duration of intensive care supports.

Recognition and management of intra-abdominal hypertension and abdominal compartment syndrome.

OBJECTIVE: To determine ICU registrars' level of awareness regarding measurement of intra-abdominal pressure (IAP), features of intra-abdominal hypertension (IAH), and management of abdominal compartment syndrome (ACS). METHODS: We surveyed 40 Australasian ICU registrars attending a post-graduate teaching course in 2004. The survey questions explored clinical experience and understanding of IAP, methods of measurement of IAP, diagnosis and causes of IAH and management of ACS in critically ill patients. RESULTS: The survey recorded a 90% response rate. Ninety two percent of the ICU registrars had used IAP in their clinical practice; 52% of those with experience in IAP measurement had only employed it infrequently. While 90% affirmed their knowledge that IAP can rise due to intraperitoneal pathology, causation of IAH by retroperitoneal conditions was poorly understood. Ninety two per cent correctly said that ACS should be treated by abdominal decompression. Only 70% of our respondents felt confident not to perform a computed tomography (CT) scan of the abdomen before treating a patient with ACS. The majority understood the need for, and the modes of, therapy for ACS; but 33 % erroneously said that they would treat IAP > 30 mmHg regardless of organ dysfunction and another 22 % were unsure of the threshold of therapy for ACS. CONCLUSIONS: ICU registrars in Australasia appreciate the techniques for, and significance of, IAP measurements and recognise and treat ACS appropriately. Retroperitoneal causes of IAH and the threshold for treatment for ACS were not well understood by the respondents.

Acute autoimmune cardiomyopathy in primary antiphospholipid antibody syndrome.

We present a case of acute pulmonary oedema as the first presentation of autoimmune cardiomyopathy in primary antiphospholipid antibody syndrome in a patient who had no previous cardiac history. Five days of methylprednisolone at 500 mg/day followed by 100 mg/day for 10 days and then a weaning course of oral prednisone resulted in effective resolution of the acute diffuse cardiomyopathy. Her cardiac status became clinically and echocardiographically normal. We illustrate the effectiveness of immunosuppressive therapy as an adjunct to standard anti-failure measures in such presentations and we outline the association between antiphospholipid antibodies and cardiac dysfunction.

Acute lithium intoxication.

We present a case of acute lithium intoxication in a 51-year-old woman on chronic lithium therapy. Her serum lithium level was 10.6 mmol/l 13 hours after ingestion and 5.8 mmol/l at 24 hours. Dialysis therapy was not employed and she recovered well after fluid resuscitation. Serum lithium levels in chronic intoxication are more indicative of intracellular lithium concentration and therefore of clinical toxicity, as opposed to serum lithium levels in acute intoxication. Clinical features of toxicity are more important than a spot lithium level. A combination of clinical toxicity, the duration of exposure and a serial profile of serum lithium levels should guide dialytic therapy for removal of lithium.

Potential dangers of the Valsalva maneuver and adenosine in paroxysmal supraventricular tachycardia--beware preexcitation.

Paroxysmal supraventricular tachycardia (PSVT) is a common clinical problem. Valsalva maneuver and adenosine are effective therapies for many patients with PSVT, although any conversion to an irregular or wide complex tachycardia should prompt consideration of a preexcitation syndrome. We report a case where the Valsalva maneuver and adenosine, in a patient with PSVT and previously undiagnosed Wolff-Parkinson-White syndrome, caused atrial fibrillation and led to a haemodynamically unstable wide complex tachycardia and ventricular fibrillation. In PSVT, where preexcitation has not been excluded, the Valsalva maneuver and adenosine can be potentially dangerous.

Peritoneal lavage cell count ratio in blunt abdominal trauma--a useful tool in hollow viscus injury?

A 40-year-old man suffered severe orthopaedic and maxillo-facial injuries in a motor vehicle accident. After resuscitation he underwent extensive orthopaedic surgery to manage his fractures. A diagnostic peritoneal lavage just prior to his operation revealed a red blood cell count of 0.15 x 10(12)/L and white blood cell count of 3.3 x 10(12)/L. However, as the patient was haemodynamically stable, a non-operative approach was adopted. Despite a normal abdominal ultrasound, near-normal abdominopelvic computed tomography, haemodynamic stability and tolerance of enteral feeding, the patient suffered a delayed sigmoid colonic perforation eight days after the initial trauma. While abdominal computed tomography has replaced diagnostic peritoneal lavage in evaluation of blunt abdominal trauma, this case highlights the need for a more effective tool for diagnosing hollow viscus injury. In this regard, the peritoneal lavage cell count ratio (which in retrospect in our patient indicated hollow viscus injury) may be useful.

Helicopter in transit care of the critically ill--the Whangarei experience.

AIMS: To describe our experience in transit care of the critically ill in Northland and to highlight the multidisciplinary co-operation which renders this an efficient model of transit care in suburban and rural areas. METHODS: Since its inception in 1988, Northland's wholly community owned rescue helicopter has played an integral part in transit Intensive Care in Northland. This aids in transportation of medical and nursing intensive care staff to outlying primary hospitals for patient stabilisation, subsequent transfer of the patient to the intensive care unit (ICU) in Whangarei and, occasionally, for transfer to specialised critical care services in Auckland. RESULTS: As of August 1999, over 3,900 helicopter missions have been accomplished. A doctor, vetting each request for Medevac, minimises over-triage, thus ensuring adequate levels of transit care and effective utilisation of expensive resources. More than 90% of non-obstetric adult patients were ventilated and the number of Medevac missions increased over the years. The Accident Compensation Corporation (ACC) funds 40% of all flights, another 40% of flights are funded by Northland Health and the Order of St John funds the remainder. CONCLUSIONS: With a widespread geography, efficient transit care of the critically ill is imperative to quality hospital care and ensures equity of access to the rural populace. The Whangarei system of transit intensive care is an ideal template for suburban and rural areas.

Pyridoxine therapy in a patient with severe hydrazine sulfate toxicity.

OBJECTIVE: To report hydrazine sulfate as a cause of severe encephalopathy and to report its response to high-dose pyridoxine therapy. DESIGN: Case report. SETTING: An adult six-bed medical/surgical intensive care unit of a general hospital. PATIENT: One patient who developed severe encephalopathy after hydrazine sulfate. INTERVENTION: 5 g i.v. pyridoxine. MEASUREMENTS AND MAIN RESULTS: After 180 mg/day for 2 wks followed by 360 mg/day of hydrazine sulfate ingestion, our patient suffered severe encephalopathy. He received mechanical ventilation with attendant supportive measures and high-dose pyridoxine. The patient's encephalopathy resolved 24 hrs after receiving pyridoxine. CONCLUSION: Severe encephalopathy could result from hydrazine sulfate toxicity. High-dose pyridoxine is an effective treatment to reverse this encephalopathy.

Null alleles at the Huntington disease locus: implications for diagnostics and CAG repeat instability.

PCR amplification of the CAG repeat in exon 1 of the IT15 gene is routinely undertaken to confirm a clinical diagnosis of Huntington disease (HD) and to provide predictive testing for at-risk relatives of affected individuals. Our studies have detected null alleles on the chromosome carrying the expanded repeat in three of 91 apparently unrelated HD families. Sequence analysis of these alleles has revealed the same mutation event, leading to the juxtaposition of uninterrupted CAG and CCG repeats. These data suggest that a mutation-prone region exists in the IT15 gene bounded by the CAG and CCG repeats and that caution should be exercised in designing primers that anneal to the region bounded by these repeats. Two of the HD families segregated null alleles with expanded uninterrupted CAG repeats at the lower end of the zone of reduced penetrance. The expanded repeats are meiotically unstable in these families, although this instability is within a small range of repeat lengths. The haplotypes of the disease-causing chromosomes in these two families differ, only one of which is similar to that reported previously as being specific for new HD mutations. Finally, no apparent mitotic instability of the uninterrupted CAG repeat was observed in the brain of one of the HD individuals.

Patient Care Bridge--mobile ICU for transit care of the critically ill.

We describe the development and introduction of a Patient Care Bridge--a mobile ICU for the transit care of the critically ill. This stretcher-mounted Patient Care Bridge is being used for intensive transit care of the critically ill in Northland, New Zealand. It carries all the basic intensive care monitoring accoutrements, is lightweight and is suited for pre-hospital, inter-hospital and intra-hospital transit care. It is ideal for patient evacuation from the scene of motor vehicle and sporting accidents, surface transportation of patients by surface ambulance and aeroevacuation of patients by the Helicopter Emergency Medical Service. This economic and space efficient unit has been used for transfer of more than one thousand critically ill patients.

Second response to immunoglobulin in recurrent Guillain-Barré syndrome.

Guillain-Barré, syndrome is the most common paralytic illness among healthy adults. With modern critical care, the mortality has fallen although prolonged hospitalisation and significant morbidity are common. Plasma exchange and intravenous immunoglobulin have only recently been shown to be equally efficacious; the combination of plasma exchange plus intravenous immunoglobulin does not confer additional advantage. Contrary to earlier fears, immunoglobulin use is not associated with an increased relapsed rate. Some patients do benefit from a second course of immunoglobulin in recurrent Guillain-Barré syndrome.

Fungal peritonitis in continuous ambulatory peritoneal dialysis--the Auckland experience.

Fungal infection is an uncommon cause of peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD). We report our center's experience with 38 episodes of fungal peritonitis occurring in 33 patients, out of a total of 503 patients managed on CAPD over 11 1/2 years, and review the relevant literature. Our usual management philosophy has been one of early peritoneal catheter removal without antifungal therapy. In those with worsening clinical features, and in those with persistence of signs and symptoms beyond 48 hours after catheter removal, antifungal drugs were administered. Only five patients received antifungal therapy initially, followed by later catheter removal. Seventy-six percent of patients treated by catheter removal alone (N = 21) and 64% of patients treated by catheter removal followed by antifungal therapy (N = 11) were successfully reestablished on CAPD. A policy of early catheter removal, usually alone, but followed by antifungal therapy in select cases, can be associated with a mortality rate of less than 15% and a high rate of return to effective peritoneal dialysis.

Bilateral emphysematous pyelonephritis resolving to medical therapy.

We describe a case of bilateral emphysematous pyelonephritis, in a diabetic female, that responded to medical therapy alone. Her complete improvement is documented radiologically. Emphysematous pyelonephritis, as a cause of serious infection in diabetic patients, is briefly reviewed.

Eosinophilic granuloma of mandible in an adult (a case report).

A case of mono-ostotic eosinophilic granuloma localised to the mandible of an adult patient is described. The role of low dose radiation therapy as a curative modality is discussed.