The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. The development and evaluation of an incident reporting system in intensive care

Publisher's copy made available with the permission of the publisher © 1996 Australian Society of AnaesthetistsIntensive care units are complex, dynamic patient management environments. Incidents and accidents can be caused by human error, by problems inherent in complex systems, or by a combination of these. Study objectives were to develop and evaluate an incident reporting system. A report form was designed eliciting a description of the incident, contextual information and contributing factors. Staff group sessions using open-ended questions, observations in the workplace and a review of earlier narratives were used to develop the report form. Three intensive care units participated in a two-month evaluation study. Feedback questionnaires were used to assess staff attitudes and understanding, project design and organization. These demonstrated a positive attitude and good understanding by more than 90% participants. Errors in communication, technique, problem recognition and charting were the predisposing factors most commonly chosen in the 128 incidents reported. It was concluded that incident monitoring may be a suitable technique for improving patient safety in intensive care.U. Beckman, L.F. West, G.J. Groombridge, I. Baldwin, G.K. Hart, D.G. Clayton, R.K. Webb, W.B. Runcima

Allergic bronchopulmonary aspergillosis: diagnostic and treatment challenges

Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder, occurring mostly in asthmatic and cystic fibrosis patients, caused by an abnormal T-helper 2 lymphocyte response of the host to Aspergillus fumigatus antigens. ABPA diagnosis is defined by clinical, laboratory and radiological criteria including active asthma, immediate skin reactivity to A. fumigatus antigens, total serum IgE levels>1000 IU/mL, fleeting pulmonary parenchymal opacities and central bronchiectases that represent an irreversible complication of ABPA. Despite advances in our understanding of the role of the allergic response in the pathophysiology of ABPA, pathogenesis of the disease is still not completely clear. In addition, the absence of consensus regarding its prevalence, diagnostic criteria and staging limits the possibility of diagnosing the disease at early stages. This may delay the administration of a therapy that can potentially prevent permanent lung damage. Long-term management is still poorly studied. Present primary therapies, based on clinical experience, are not yet standardized. These consist in oral corticosteroids, which control acute symptoms by mitigating the allergic inflammatory response, azoles and, more recently, anti-IgE antibodies. The latter two are used as a steroid-sparing agent to prolong the remission stage of the disease. Anti-IgE antibodies also have immunomodulatory properties. At present, the only way to bypass these limits and allow for an early diagnosis, is to assume ABPA in all patients with difficult-to-control asthma or cystic fibrosis. They should then be screened for sensitization to A. fumigatus antigens and, if positive, monitored more closely. Future controlled studies are needed to standardize present therapy, standardize cut-off values of various investigations, define the role of different novel immunomodulatory therapies, define the role of novel assays (such as recombinant A. fumigatus antigens and CCL17) and confirm new diagnostic and staging criteria

Developing a model for cystic fibrosis sociomicrobiology based on antibiotic and environmental stress

Cystic fibrosis (CF) infections are invariably biofilm-mediated and polymicrobial, being safe to assume that a myriad of factors affects the sociomicrobiology within the CF infection site and modulate the CF community dynamics, by shaping their social activities, overall functions, virulence, ultimately affecting disease outcome. This work aimed to assess changes in the dynamics (particularly on the microbial composition) of dual-/three-species biofilms involving CF-classical (Pseudomonas aeruginosa) and unusual species (Inquilinus limosus and Dolosigranulum pigrum), according to variable oxygen conditions and antibiotic exposure. Low fluctuations in biofilm compositions were observed across distinct oxygen environments, with dual-species biofilms exhibiting similar relative proportions and P. aeruginosa and/or D. pigrum populations dominating three-species consortia. Once exposed to antibiotics, biofilms displayed high resistance profiles, and microbial compositions, distributions, and microbial interactions significantly challenged. The antibiotic/oxygen environment supported such fluctuations, which enhanced for three-species communities. In conclusion, antibiotic therapy hugely disturbed CF communities dynamics, inducing significant compositional changes on multispecies consortia. Clearly, multiple perturbations may disturb this dynamic, giving rise to various microbiological scenarios in vivo, and affecting disease phenotype. Therefore, an appreciation of the ecological/evolutionary nature within CF communities will be useful for the optimal use of current therapies and for newer breakthroughs on CF antibiotherapy.This study was supported by the Portuguese Foundation for Science and Technology (FCT) under the scope of the strategic funding of UID/ BIO/04469/2013 unit and COMPETE 2020 (POCI-01-0145-FEDER006684). The authors also acknowledge the financial support provided by FCT through the projects: PTDC/SAU-ESA/646091/2006/ FCOMP01-0124-FEDER-007480FCT; strategic project PEst-OE/EQB/LA0023/2013; “BioHealth – Biotechnology and Bioengineering approaches to improve health quality”, Ref. NORTE-07-0124-FEDER-000027, cofunded by the Programa Operacional Regional do Norte (ON.2–O Novo Norte), QREN, FEDER; RECI/BBB-EBI/0179/2012 – Consolidating Research Expertise and Resources on Cellular and Molecular Biotechnology at CEB/IBB, FCOMP-01-0124-FEDER-027462, FEDER; and the DNA mimics project PIC/IC/82815/2007. The FCT BPD fellowship of Susana P. Lopes SFRH/BPD/95616/2013 and the support of the COST-Action TD1004:Theragnostics for imaging and therapy is also acknowledged.info:eu-repo/semantics/publishedVersio

Assessment of Occupational Diseases among Artisans and Factory Workers in Ifo, Nigeria

The ever increasing incidences of occupational diseases among workers have continually drawn the attention of researchers towards ameliorating the situation. Investigation was launched to assess occupational diseases among artisans and factory workers in Ifo, Nigeria. Structured questionnaires with oral interview were employed to complement the health records of the respondents at the Government accredited health center. Of the one hundred and fifty six (156) respondents, ninety six (62%) are males and sixty one (38%) female, sixty one point fifty four percent (61.54%) are youths of age 20 to 39 years, fifty one (32.69%) are illiterates and one hundred and eight (69.21%) earn N100, 000 ($615) and below as monthly wages. The diseases prevalent in these workers were evaluated to include but not limited to disorders of muscles, bones, joints, skin and the respiratory organs indicating that most of the jobs are such that causes damages to these special parts of the body and could lead to deformities/incapacitation in old age. Common amongst these diseases are Pre-patellar bursitis and Eczema (1.92% each), Tuberculosis, Asthma and Sunburn (5.77% each). Toxic/inflammatory syndrome, hearing impairment, allergies and computer vision syndrome (7.69% each). Two (1.28% in each case) have been diagnosed of Lead poisoning, Lung cancer, Carpal tunnel syndrome, Pulmonary fibrosis, Meniscus lesion and Olecranon bursitis. Upper airway disorders (4.49%), Irritations (3.21%), Post-traumatic stress syndrome (11.54%), skin allergies (13.46%). Chronic bronchitis; Pneumonia; Pneumoconiosis; Hepatitis and Anthrax-like infection (0.64 % each). The causes of these diseases/disorders include dusts from quarry, textile, cotton, metal, paper, mineral, wood, cereals, cement, and chemical fumes industries, extreme posture of wrist, repetitive movements, inhalations from petrol fuel, prolonged pressure of the elbow region, prolonged kneeling/ squatting position, forceful exertions and microorganisms. Adequate occupational health and safety awareness through training and campaign should be provided. The use of personal protective equipment among workers should also be encouraged

Managing and Controlling the Thermal Environment in Underground Metal Mines

The main aim of this research work was to discuss the methods of identifying and control heat in underground mine environments. The research contains three main sections as follow:1. Selecting an appropriate heat stress index for underground mining applicationMethods: The aim of this research study was to discuss the challenges in identifying and selecting an appropriate heat stress index for thermal planning and management purposes in underground mines. A method was proposed coupled to a defined strategy for selecting and recommending heat stress indices to be used in underground metal mines in the US and worldwide based on a thermal comfort model. Results: The performance of current heat stress indices used in underground mines varies based on the climatic conditions and the level of activities. Therefore, by carefully selecting or establishing an appropriate heat stress index is of paramount importance to ensure the safety, health and increasing productivity of the underground workers.Conclusions: This method presents an important tool to assess and select the most appropriate index for certain climatic conditions in order to protect the underground workers from heat related illnesses. Although complex, the method presents results that are easy to interpret and understand than any of the currently available evaluation methods.2. Best practices in use of continuous climatic monitoring systems for assessment of underground mine climatic condition:Methods: Major heat sources in an underground metal mine in Nevada was quantified using over one year of climatic data collection in both primary and auxiliary ventilation systems. Furthermore, auxiliary ventilation systems were examined in a development heading and a production area at our partner mine. Climatic models were developed and validated to simulate the climatic conditions based on intake airflow conditions and the heat load along the ducting system. Considerations were also given to the fact that arsenic concentrations may be present at the face. Different scenarios were studied to design and optimize the auxiliary ventilation systems in order to minimize the heat generated by multiple auxiliary fans and minimize arsenic concentration in the production workings.Results: The results show that the heat generated by different major heat sources can change throughout the mine as a function of surface temperature. Furthermore, current auxiliary ventilation design cannot maintain the comfort limits of the underground workers. In some cases, some type of cooling system must be utilized to retain the thermal comfort in production workings. Conclusions: In many instances, by simply adjusting or upgrading the auxiliary ventilation system in a problem area of a mine will effectively dilute the pollutants that are generated during production operations and provide adequate climatic conditions to the mine workers. This can be achieved through various methods such as: (1) extending the auxiliary duct towards the face, (2) installing an additional auxiliary fan to overcome the added pressure losses in the system, (3) changing the size of the fan, (4) switching from an “exhausting” arrangement to a “forcing” arrangement, and (5) installing an “overlap” auxiliary ventilation system.3. Quantifying the thermal damping effect in underground vertical openings using artificial neural network:Method: A nonlinear autoregressive time series with external input (NARX) algorithm was used as a novel method to predict the dry-bulb temperature (Td) at the bottom of the shaft as a function of surface air temperature. Furthermore, an attempt was made to quantify typical “damping coefficient” for both production and ventilation shafts through simple linear regression models.Results: The performance of the model was examined using climatic data collected at two underground mines during summer and winter. Analyses demonstrated that the artificial neural network (ANN) model could accurately predict the temperature at the bottom of a shaft. Comparisons between the collected climatic data and the regression-based predictions show that a simple linear regression model provides an acceptable prediction of the Td at the bottom of intake shafts. The same approach can be used to predict the thermal damping effect on the wet-bulb temperature (Tw) at the bottom of production and ventilation shafts.Conclusions: A comparison between collected data and the climatic modeling demonstrates that the ventilation or climatic modeling software packages do not have the ability take into account the “thermal damping effect (TDE)” (also known as thermal flywheel effect) when modeling the thermal environment in deep and hot underground mines. The major difficulty in incorporating TDE comes from a large number of variables interacting with each other plus the time-dependent heat and mass transport processes that control the flow of strata heat into/from the mine airways

Patterns of unexpected in-hospital deaths: a root cause analysis

<p>Abstract</p> <p>Background</p> <p>Respiratory alarm monitoring and rapid response team alerts on hospital general floors are based on detection of simple numeric threshold breaches. Although some uncontrolled observation trials in select patient populations have been encouraging, randomized controlled trials suggest that this simplistic approach may not reduce the unexpected death rate in this complex environment. The purpose of this review is to examine the history and scientific basis for threshold alarms and to compare thresholds with the actual pathophysiologic patterns of evolving death which must be timely detected.</p> <p>Methods</p> <p>The Pubmed database was searched for articles relating to methods for triggering rapid response teams and respiratory alarms and these were contrasted with the fundamental timed pathophysiologic patterns of death which evolve due to sepsis, congestive heart failure, pulmonary embolism, hypoventilation, narcotic overdose, and sleep apnea.</p> <p>Results</p> <p>In contrast to the simplicity of the numeric threshold breach method of generating alerts, the actual patterns of evolving death are complex and do not share common features until near death. On hospital general floors, unexpected clinical instability leading to death often progresses along three distinct patterns which can be designated as Types I, II and III. Type I is a pattern comprised of hyperventilation compensated respiratory failure typical of congestive heart failure and sepsis. Here, early hyperventilation and respiratory alkalosis can conceal the onset of instability. Type II is the pattern of classic CO2 narcosis. Type III occurs only during sleep and is a pattern of ventilation and SPO2 cycling caused by instability of ventilation and/or upper airway control followed by precipitous and fatal oxygen desaturation if arousal failure is induced by narcotics and/or sedation.</p> <p>Conclusion</p> <p>The traditional threshold breach method of detecting instability on hospital wards was not scientifically derived; explaining the failure of threshold based monitoring and rapid response team activation in randomized trials. Furthermore, the thresholds themselves are arbitrary and capricious. There are three common fundamental pathophysiologic patterns of unexpected hospital death. These patterns are too complex for early detection by any unifying numeric threshold. New methods and technologies which detect and identify the actual patterns of evolving death should be investigated.</p