Tick-box admission forms improve the quality of documentation of surgical emergencies, but have limited impact on clinical behaviour

Introduction. We used modern error theory to develop a tick-box admission form for emergency surgical patients. The tick boxes were designed to actively direct care down appropriate clinical algorithms by encouraging staff to make decisions based on recorded clinical data.Objective. To audit the effect of these tick-box forms on the quality of documentation and of the resuscitation process.Methods. We designed and implemented a standardised tick-box admission form, and audited its impact by comparing 100 emergency surgical admissions before the intervention with 100 thereafter. We assessed the quality of the documentation in both groups and analysed the effect of use of the tick-box admission form and the decision nodes on the clinical behaviour of the admitting clinicians.Results. The introduction of standardised tick-box admission forms dramatically improved the quality of documentation of acute surgical admissions. However, the impact of the decision nodes on clinical behaviour was less obvious. We demonstrated a tendency to cognitive dissonance in that, even though clinicians recorded abnormal physiological data, they did not consistently interpret this information correctly.Conclusions. Although the use of tick-box admission forms improves the quality of documentation, the impact on clinical behaviour is less certain. Quality improvement is a multifactorial endeavour, and without a pervasive culture of patient safety, tick-boxes alone may well be ineffective

Hybrid electronic record: An error reduction strategy for diverse medical prescription formats

Background: This project is part of a broader effort to develop a new electronic registry for ophthalmology in the KwaZulu-Natal (KZN) province in South Africa. The registry should include a clinical decision support system that reduces the potential for human error and should be applicable for our diversity of hospitals, whether electronic health record (EHR) or paper-based. Methods: Post-operative prescriptions of consecutive cataract surgery discharges were included for 2019 and 2020. Comparisons were facilitated by the four chosen state hospitals in KZN each having a different system for prescribing medications: Electronic, tick sheet, ink stamp and handwritten health records. Error types were compared to hospital systems to identify easily-correctable errors. Potential error remedies were sought by a four-step process. Results: There were 1307 individual errors in 1661 prescriptions, categorised into 20 error types. Increasing levels of technology did not decrease error rates but did decrease the variety of error types. High technology scripts had the most errors but when easily correctable errors were removed, EHRs had the lowest error rates and handwritten the highest. Conclusion: Increasing technology, by itself, does not seem to reduce prescription error. Technology does, however, seem to decrease the variability of potential error types, which make many of the errors simpler to correct. Contribution: Regular audits are an effective tool to greatly reduce prescription errors, and the higher the technology level, the more effective these audit interventions become. This advantage can be transferred to paper-based notes by utilising a hybrid electronic registry to print the formal medical record

Burn surgeons in South Africa: A rare species

Background. The high burden of burn injuries in South Africa (SA) requires surgeons skilled in burn care. However, there are few dedicated burn surgeons and properly equipped units or centres.Objectives. To quantify the involvement of surgeons in burn care in SA hospitals, identify factors that attract surgeons to pursue burn care as a career and deter them from doing so, and understand the challenges of hospitals treating burn patients around the country.Methods. This was a prospective, qualitative study. Questionnaires were handed out at the South African Burn Society Congress in September 2013 and a trade symposium in March 2014.Results. One hundred questionnaires were handed out, and there was a 70% response rate. Twenty-six (39%) of the respondents had a specialist surgical qualification. Only half the units had registrars (48%) and interns (51%) on their staff. Only 30% of the respondents were dedicated to burn care alone, the majority being involved on a part-time basis. The most common factor respondents suggested was needed to recruit future burn care providers, cited by 76%, was better facilities and resources. Other factors included training and skills development (59%), subspecialist training (55%), development of a diploma in burn care (52%), development of research (52%) and healthcare worker psychological support (45%).Discussion. We have demonstrated that current workforce resources for burn care are inadequate, the major deficit being lack of training and the resource-restricted environment. This survey provides basic information towards workforce planning, which can be used to inform the necessary strategic decisions

A retrospective audit of nursing-related morbidity recorded in a state hospital in KwaZulu-Natal

Background: Health care professionals are expected to deliver safe and effective health services; however there is increased realisation that adverse events in the health system are a major cause of preventable morbidity and mortality. Objectives: To conduct a retrospective audit of nursing-related morbidities in a state hospital in KwaZulu-Natal, South Africa. Method: A retrospective audit of nursing-related morbidities documented by the surgical service was carried out using the Hybrid Electronic Medical Registry data for a period of 3 years – 01 November 2013 to 31 October 2016. Results: There were a total of 12 444 admissions to surgical service during the study period, with 461 nursing-related morbidities reported. There was an increase in the number of documented nursing-related morbidities noted during November 2015 to October 2016, with 79% of all reported nursing-related morbidities documented during this period. A total of 54% of nursing-related morbidities were associated with males (n = 248) and 46% (n = 213) with females. The most commonly documented nursing-related morbidity was drugs/medication (n = 167, 36%) with the second most common being adjunct management (n = 130, 28%). Conclusion: The study has identified the most commonly documented nursing-related morbidities in the surgical service of a state hospital. The findings of the study could provide direction for further research and educational initiatives

An audit of traumatic brain injury (TBI) in a busy developing-world trauma service exposes a significant deficit in resources available to manage severe TBI.

BACKGROUND: Traumatic brain injury (TBI) affects large numbers of patients, both adults and children, and significant resources are needed to manage it. OBJECTIVE: To determine the burden of TBI and the adequacy of available resources to manage in the Pietermaritzburg Metropolitan Trauma Service (PMTS). METHODS: All patients with a TBI were identified from the hybrid electronic medical registry at Grey's and Edendale hospitals in Pietermaritzburg (PMB), KwaZulu-Natal, South Africa. Patients were classified according to severity of head injury and age. We defined mild TBI as Glasgow coma scale (GCS) 13 - 15, moderate as GCS 9 - 12, and severe as GCS ≤8, in accordance with international standards. We divided the cohort according to ages 0 - 5 years, 6 - 10 years, >10 - 17 years and adults (>17 years). RESULTS: From January 2012 to December 2014, 3 301 patients were treated for TBI in PMB. The mean age was 27.4 (standard deviation 14.4) years. There were 2 632 males and 564 females. There were 2 540 mild, 326 moderate, and 329 severe TBI admissions during the period under review. A total of 139 (4.2%) patients died. A total of 242 (7.3%) patients were admitted to the intensive care unit (ICU), of whom 137 (57.0%) had a GCS of ≤9. Only 27.0% of patients with a GCS of ≤9 were admitted to the ICU. CONCLUSION: There is a significant burden of TBI managed by the PMTS. Critical care resources available to manage patients with TBI are inadequate

An audit of traumatic brain injury (TBI) in a busy developing-world trauma service exposes a significant deficit in resources available to manage severe TBI

Background. Traumatic brain injury (TBI) affects large numbers of patients, both adults and children, and significant resources are needed to manage it.Objective. To determine the burden of TBI and the adequacy of available resources to manage in the Pietermaritzburg Metropolitan Trauma Service (PMTS). Methods. All patients with a TBI were identified from the hybrid electronic medical registry at Grey’s and Edendale hospitals in Pietermaritzburg (PMB), KwaZulu-Natal, South Africa. Patients were classified according to severity of head injury and age. We defined mild TBI as Glasgow coma scale (GCS) 13 - 15, moderate as GCS 9 - 12, and severe as GCS ≤8, in accordance with international standards. We divided the cohort according to ages 0 - 5 years, 6 - 10 years, >10 - 17 years and adults (>17 years). Results. From January 2012 to December 2014, 3 301 patients were treated for TBI in PMB. The mean age was 27.4 (standard deviation 14.4) years. There were 2 632 males and 564 females. There were 2 540 mild, 326 moderate, and 329 severe TBI admissions during the period under review. A total of 139 (4.2%) patients died. A total of 242 (7.3%) patients were admitted to the intensive care unit (ICU), of whom 137 (57.0%) had a GCS of ≤9. Only 27.0% of patients with a GCS of ≤9 were admitted to the ICU. Conclusion. There is a significant burden of TBI managed by the PMTS. Critical care resources available to manage patients with TBI are inadequate.

The effect of HIV status on clinical outcomes of surgical sepsis in KwaZulu-Natal Province, South Africa.

BACKGROUND: KwaZulu-Natal Province, South Africa (SA), has long been the epicentre of the HIV epidemic, but the impact of HIV co-infection on the clinical outcomes of emergency surgical patients with sepsis remains largely unknown. OBJECTIVE: To review our experience with the management of patients with HIV co-infection and to compare the disease spectrum and outcome with those without HIV infection. METHODS: A retrospective study was undertaken at the Pietermaritzburg Metropolitan Surgical Service (PMSS), SA over a 5-year period from January 2010 to December 2014. RESULTS: A total of 675 patients with a documented surgical source of sepsis were reviewed. Of these, 332 (49%) were male, and the mean age was 46 (standard deviation 19) years. HIV status was known in 237 (35%) patients, 146 (62%) were HIV-positive and the remaining 91 (38%) were HIV-negative. Other than tuberculosis of the abdomen being significantly more common in HIV-positive than HIV-negative patients (10% v. 2%, p=0.033), there were no differences in the spectrum of diseases between the two groups. There were no significant differences in overall morbidity or mortality. When adjusted for CD4 counts, the mortality in HIV-positive patients with a CD4 count <200 cells/μL was 60% (15/25) and in those with a CD4 count >200 cells/μL it was 2% (2/101) (p<0.001). CONCLUSION: The clinical presentation and the spectrum of surgical sepsis in patients with HIV co-infection were not markedly different to those in patients who were not HIV-infected. HIV-infected patients with a CD4 count <200 cells/μL had a significantly higher mortality. Management approaches should not differ based solely on the HIV status of patients with surgical sepsis

The effect of HIV status on clinical outcomes of surgical sepsis in KwaZulu-Natal Province, South Africa

Background. KwaZulu-Natal Province, South Africa (SA), has long been the epicentre of the HIV epidemic, but the impact of HIV co-infection on the clinical outcomes of emergency surgical patients with sepsis remains largely unknown.Objective. To review our experience with the management of patients with HIV co-infection and to compare the disease spectrum and outcome with those without HIV infection.Methods. A retrospective study was undertaken at the Pietermaritzburg Metropolitan Surgical Service (PMSS), SA over a 5-year period from January 2010 to December 2014.Results. A total of 675 patients with a documented surgical source of sepsis were reviewed. Of these, 332 (49%) were male, and the mean age was 46 (standard deviation 19) years. HIV status was known in 237 (35%) patients, 146 (62%) were HIV-positive and the remaining 91 (38%) were HIV-negative. Other than tuberculosis of the abdomen being significantly more common in HIV-positive than HIV-negative patients (10% v. 2%, p=0.033), there were no differences in the spectrum of diseases between the two groups. There were no significant differences in overall morbidity or mortality. When adjusted for CD4 counts, the mortality in HIV-positive patients with a CD4 count <200 cells/μL was 60% (15/25) and in those with a CD4 count >200 cells/μL it was 2% (2/101) (p<0.001).Conclusion. The clinical presentation and the spectrum of surgical sepsis in patients with HIV co-infection were not markedly different to those in patients who were not HIV-infected. HIV-infected patients with a CD4 count <200 cells/μL had a significantly higher mortality. Management approaches should not differ based solely on the HIV status of patients with surgical sepsis

Inhibition of sarcolemmal FAT/CD36 by sulfo-N-succinimidyl oleate rapidly corrects metabolism and restores function in the diabetic heart following hypoxia/reoxygenation.

AIMS: The type 2 diabetic heart oxidizes more fat and less glucose, which can impair metabolic flexibility and function. Increased sarcolemmal fatty acid translocase (FAT/CD36) imports more fatty acid into the diabetic myocardium, feeding increased fatty acid oxidation and elevated lipid deposition. Unlike other metabolic modulators that target mitochondrial fatty acid oxidation, we proposed that pharmacologically inhibiting fatty acid uptake, as the primary step in the pathway, would provide an alternative mechanism to rebalance metabolism and prevent lipid accumulation following hypoxic stress. METHODS AND RESULTS: Hearts from type 2 diabetic and control male Wistar rats were perfused in normoxia, hypoxia and reoxygenation, with the FAT/CD36 inhibitor sulfo-N-succinimidyl oleate (SSO) infused 4 min before hypoxia. SSO infusion into diabetic hearts decreased the fatty acid oxidation rate by 29% and myocardial triglyceride concentration by 48% compared with untreated diabetic hearts, restoring fatty acid metabolism to control levels following hypoxia-reoxygenation. SSO infusion increased the glycolytic rate by 46% in diabetic hearts during hypoxia, increased pyruvate dehydrogenase activity by 53% and decreased lactate efflux rate by 56% compared with untreated diabetic hearts during reoxygenation. In addition, SSO treatment of diabetic hearts increased intermediates within the second span of the Krebs cycle, namely fumarate, oxaloacetate, and the FAD total pool. The cardiac dysfunction in diabetic hearts following decreased oxygen availability was prevented by SSO-infusion prior to the hypoxic stress. Infusing SSO into diabetic hearts increased rate pressure product by 60% during hypoxia and by 32% following reoxygenation, restoring function to control levels. CONCLUSIONS: Diabetic hearts have limited metabolic flexibility and cardiac dysfunction when stressed, which can be rapidly rectified by reducing fatty acid uptake with the FAT/CD36 inhibitor, SSO. This novel therapeutic approach not only reduces fat oxidation but also lipotoxicity, by targeting the primary step in the fatty acid metabolism pathway

Novel ketone diet enhances physical and cognitive performance.

Ketone bodies are the most energy-efficient fuel and yield more ATP per mole of substrate than pyruvate and increase the free energy released from ATP hydrolysis. Elevation of circulating ketones via high-fat, low-carbohydrate diets has been used for the treatment of drug-refractory epilepsy and for neurodegenerative diseases, such as Parkinson's disease. Ketones may also be beneficial for muscle and brain in times of stress, such as endurance exercise. The challenge has been to raise circulating ketone levels by using a palatable diet without altering lipid levels. We found that blood ketone levels can be increased and cholesterol and triglycerides decreased by feeding rats a novel ketone ester diet: chow that is supplemented with (R)-3-hydroxybutyl (R)-3-hydroxybutyrate as 30% of calories. For 5 d, rats on the ketone diet ran 32% further on a treadmill than did control rats that ate an isocaloric diet that was supplemented with either corn starch or palm oil (P < 0.05). Ketone-fed rats completed an 8-arm radial maze test 38% faster than did those on the other diets, making more correct decisions before making a mistake (P < 0.05). Isolated, perfused hearts from rats that were fed the ketone diet had greater free energy available from ATP hydrolysis during increased work than did hearts from rats on the other diets as shown by using [31P]-NMR spectroscopy. The novel ketone diet, therefore, improved physical performance and cognitive function in rats, and its energy-sparing properties suggest that it may help to treat a range of human conditions with metabolic abnormalities.-Murray, A. J., Knight, N. S., Cole, M. A., Cochlin, L. E., Carter, E., Tchabanenko, K., Pichulik, T., Gulston, M. K., Atherton, H. J., Schroeder, M. A., Deacon, R. M. J., Kashiwaya, Y., King, M. T., Pawlosky, R., Rawlins, J. N. P., Tyler, D. J., Griffin, J. L., Robertson, J., Veech, R. L., Clarke, K. Novel ketone diet enhances physical and cognitive performance.A.J.M. thanks the Research Councils UK for supporting his Academic Fellowship. This work was supported by the Defense Advanced Research Projects Agency.This is the final version of the article. It first appeared from FASEB at https://doi.org/10.1096/fj.201600773R