Preparation for hospital accreditation: an efficient and practical approach.

Hospital accreditation has been criticized for its emphasis on structure and documentation. Less attention is given to the clinical process and outcomes of care. How can the accreditation process become a meaningful part of day-to-day hospital management? Four approaches are discussed. (1) The development of industrial type quality assurance programmes that detect negative patient outcomes and improve patient care. (2) The appointment of a Quality Assurance/Accreditation Coordinator with appropriate authority. (3) The establishment of an effective Quality Assurance/Accreditation Committee. (4) The continuous review of accreditation standards through normal committee function and department review, and trial surveys. Such strategies will enable hospital accreditation to develop beyond a paper exercise and to provide the foundation for excellence in health care delivery.

Cutaneous nocardiosis associated with insect bites.

We report the first case of cutaneous nocardiosis associated with insect bites. The patient received these insect bites while camping a few days before he presented to the emergency room. The patient was a healthy twenty-six-year-old man, who was asplenic as a result of a motor vehicle accident. He presented to the emergency room with fever, multiple insect bites to his left lower extremity with pustules, lymphangitis, and left inguinal adenopathy. He was hospitalized but his condition failed to improve despite treatment with intravenous nafcillin for three days. Wound and blood cultures subsequently grew Nocardia brasiliensis. Treatment with intravenous amikacin (5 mg/kg every eight hours) was instituted along with oral trimethoprim-sulfamethoxazole double strength twice a day. The patient recovered with minimal scarring of the extremity. The amikacin was stopped after seven days and the patient was discharged to receive oral trimethoprim-sulfamethoxazole. This disease should be kept in mind when cutaneous infections do not respond to standard antibiotics, especially in the southwestern United States.