Supporting work practices, improving patient flow and monitoring performance using a clinical information management system

Providing information technology solutions to clinicians to support their work practices benefits clinicians, administrators and patients. We present our 8-year experience with an inexpensive information management system which provides clinical and business process support for clinicians and bed managers. The system has been used by an area rehabilitation and aged care service to manage inpatient consultations and patient flow across nine hospitals. Performance monitoring of the time from referral to consultation, the number, type and outcome of consultations, and the time taken to access a rehabilitation or subacute bed is also provided. Read-only access to the system for clinicians and bed managers outside the rehabilitation and aged care service allows greater transparency

Effects of central nervous opoid and 5-hydroxytrptamine interactions on coronary conductance regulation in the conscious dog

The synthetic opioid agonist, fentanyl, has been shown in our laboratory to cause a neurological mediated systemic vasoconstriction in man. This may include coronary vasconstriction since ST-segment depression on ECG may occur during fentanyl anaesthesia for a coronary artery bypass surgery. Systemic vascoconstriction induced by fentanyl in the rabbit is dependent on central nervous 5-hydroxytryptine (5HT). Therefore the present study was undertaken in the dog to examine the postulates that intravenous fentanyl causes coronary vascoconstriction which is dependent on CNS 5HT and that baroreflex gain of coronary conductance mediated through sympathetic and parasympathetic pathways is increased by fentanyl. Conscious dogs in experimental complete heart block paced at 100 beats/min were used; circumflex coronary flow was measured using a Doppler flowmeter; baroreflexes were evoked by inflation of a balloon placed in the descending thoracic aorta. Coronary haemodynamics were examined before, immediately after, and 7 days after intracisternal injection of 5,7-dihydroxytryptamine (5,7DHT). Fentanyl infusion (0.55 μg/kg per min) for 20 min in five dogs resulted in variable rises in mean aortic pressure (MAP). Circumflex coronary flow (CCF) fell or was unchanged. Circumflex coronary conductance fell in all five dogs, and baroreflex gain increased. Intracisternal 5,7DHT immeadiately evoked sustained rises in atrial rate and MAP but rises in CCC were poorly sustained. One week later, MAP was largely unaltered but there was a rise in resting CCC in three of four dogs. Baroreflex gain of CCC was reduced and fentanyl did not uniformly cause a rise in MAP or a fall in CCC as before but baroreflex gain was restored by fentanyl infusion. These data suggest that normally baroreflex gain of coronary conductance is under the influence of CNS opoid (fentanyl) and 5HT facillatory interactions

Central opiate system regulation of baroreflex control of coronary conductance

The central μ opiate agonist, fentanyl, causes a neurogenically mediated systemic vascoconstriction in both rabbit and man. The human coronary circulation may participate in this response, since myocardial ischaemia (ST segment depression on ECG) has been reported during fentanyl anaesthesia by Thomson et al. in a group of patients undergoing coronary artery bypass surgery. In dogs, fentanyl causes haemodynamic changes which are blocked by i.v. naloxone; there is also concommitant coronary vascoconstriction, which is prevented by prior infusion of alpha-adrenoceptor agents. In this study, central nervous opiate receptor stimulation effects on the gain of baroreflex control of coronary conductance, were examined in conscious dogs in experimental complete heart block and with ventricles paced; atrial rate was free to vary naturally. Circumflex flow was measured by Doppler flowmeter. Aortic pressure was raised by inflating a balloon in the descending thoracic aorta

Central nervous system opiate and 5-hydroxytryptamine influences on baroreflex control of the coronary circulation

The effect of intravenous infusion of fentanyl (an opiate receptor agonist, 0.55 μg kg⁻¹ min⁻¹) on the control of the circumflex coronary circulation was examined in unsedated dogs at rest and during baroreceptor stimulation evoked by acute rises in aortic pressure (balloon inflation in thoracic aorta). Circumflex flow was measured using Doppler flow transducers in dogs with experimental complete heart block and with ventricles paced at a constant rate. Studies were also performed before and one week after intracisternal injection of the neurotoxin 5,7-dihydroxytryptamine (5,7-DHT), to examine the role of CNS 5-hydroxytryptamine (5-HT) in any sympathetic vasoconstrictive effects. Fentanyl infusion caused after a few minutes a progressive rise in resting aortic pressure and a significant fall in circumflex conductance; circumflex flow usually fell. Atrial rate also fell. The gain of the baroreflex control of circumflex conductance was enhanced by fentanyl. One week after intracisternal 5,7-DHT, the gain of the baroreflex in each dog was diminished. When fentanyl was infused into these preparations, no consistent changes in resting atrial rate, aortic pressure and circumflex conductance could be observed, but all dogs showed a recovery of the coronary baroreflex gain towards values observed before intracisternal 5,7-DHT. These data suggest that the gain control of coronary baroreflexes is influenced by CNS opiate and 5-HT dependent mechanisms

Modulation of baroreflex gain regulating coronary vasodilator responses by the central μ-opioid receptor agonist fentanyl

In man and rabbit, anesthetic doses of the μ-opioid receptor agonist fentanyl cause systemic vasoconstriction. In unsedated dogs, intravenous infusion of fentanyl at 0.55 μg·kg⁻¹·min⁻¹ causes initial mild coronary vasodilatation but later vasoconstriction. Possible differential effects on baroreflex coronary vasodilator gain (ratio of percent change in circumflex conductance (CC) to aortic pressure induced by thoracic aorta balloon inflation) were studied in unsedated dogs in heart block (paced ventricles: Doppler probe on circumflex artery) during intravenous fentanyl infusion rates of 0.14, 0.28, 0.55 and 1.10 μg·kg⁻¹·min⁻¹. Fifteen minutes of fentanyl caused a rise in resting CC at the two lowest infusion rates, but a dose-dependent fall in CC and rise in aortic pressure at higher infusion rates. Gain of the vasodilator baroreflex increased at the two lowest infusion rates, but fell below pre-infusion gain at the highest infusion rates, suggesting that a physiological rise in μ-opioid receptor activity in the central nervous system may enhance baroreflex augmentation of CC in response to sudden rises in cardiac afterload. The effect is offset by coronary vasoconstriction induced during anesthetic doses

Preliminary results of patient satisfaction with nutrition handouts versus dietetic consultation in oncology outpatients receiving chemotherapy

Aim: To determine patient satisfaction with nutrition interventions in outpatients receiving chemotherapy identified as at nutritional risk.----- Methods: An observational, cross-sectional study was conducted at an Australian public hospital in 61 oncology outpatients receiving chemotherapy. A simple malnutrition screening tool was used to identify nutritional risk. Patients identified as moderate risk were triaged to receive nutrition handouts on increasing energy and protein intake. Those at high risk received nutrition counselling and support by a dietitian. Patient satisfaction was assessed using a modification of a valid and reliable satisfaction with nutrition services questionnaire.----- Results: Sixty-one patients entered the study and one-third (20/61) were at nutritional risk. Seven patients were at high risk, and received dietetic review while 13 patients were at moderate risk and received nutrition handouts. Patients identified as at nutritional risk (n = 20) were approached to complete the satisfaction with nutrition services questionnaire. Eighteen patients completed the questionnaire (n = 7: dietetic review; and n = 11: nutrition handout). Nutrition information/advice was rated as helpful (n = 15), met patient expectations (n = 16) and overall patient satisfaction was rated highly. Patients who had received a dietitian review recorded a clinically but not statistically higher overall satisfaction with nutrition services than those patients receiving the nutrition handout.----- Conclusion: The high patient satisfaction helps support nutrition intervention at the chemotherapy unit. A prospective trial is required to determine the benefits of this triage and nutrition intervention on nutrition-related outcomes