A comprehensive approach to quality management of intensive care services

Purpose – The purpose of this paper is to develop a comprehensive framework for improving intensive care unit performance. Design/methodology/approach – The study introduces a quality management framework by combining cause and effect diagram and logical framework. An intensive care unit was identified for the study on the basis of its performance. The reasons for not achieving the desired performance were identified using a cause and effect diagram with the stakeholder involvement. A logical framework was developed using information from the cause and effect diagram and a detailed project plan was developed. The improvement projects were implemented and evaluated. Findings – Stakeholders identified various intensive care unit issues. Managerial performance, organizational processes and insufficient staff were considered major issues. A logical framework was developed to plan an improvement project to resolve issues raised by clinicians and patients. Improved infrastructure, state-of-the-art equipment, well maintained facilities, IT-based communication, motivated doctors, nurses and support staff, improved patient care and improved drug availability were considered the main project outputs for improving performance. The proposed framework is currently being used as a continuous quality improvement tool, providing a planning, implementing, monitoring and evaluating framework for the quality improvement measures on a sustainable basis. Practical implications – The combined cause and effect diagram and logical framework analysis is a novel and effective approach to improving intensive care performance. Similar approaches could be adopted in any intensive care unit. Originality/value – The paper focuses on a uniform model that can be applied to most intensive care units

Immediate breast reconstruction following segmentectomy using a latissimus dorsi ‘myoadipose’ flap through a single axillary incision: a case series

Immediate breast reconstruction is an excellent complementary treatment for patients with ductal carcinoma in situ and early-stage invasive breast cancer. Although lattisimus dorsi myocutaneous flap is one of the well accepted and versatile methods of breast reconstruction, there have been very few reports describing a myoadipose flap, especially through the same axillary incision used for nodal clearance. This article describes such a technique which produced excellent results both surgically as well as cosmetically

Managing healthcare performance in analytical framework

Purpose – The purpose of the paper is to develop an integrated framework for performance management of healthcare services. Design/methodology/approach – This study develops a performance management framework for healthcare services using a combined analytic hierarchy process (AHP) and logical framework (LOGFRAME). The framework is then applied to the intensive care units of three different hospitals in developing nations. Numerous focus group discussions were undertaken, involving experts from the specific area under investigation. Findings – The study reveals that a combination of outcome, structure and process-based critical success factors and a combined AHP and LOGFRAME-based performance management framework helps manage performance of healthcare services. Practical implications – The proposed framework could be practiced in hospital-based healthcare services. Originality/value – The conventional approaches to healthcare performance management are either outcome-based or process-based, which cannot reveal improvement measures appropriately in order to assure superior performance. Additionally, they lack planning, implementing and evaluating improvement projects that are identified from performance measurement. This study presents an integrated approach to performance measurement and implementing framework of improvement projects

Bariatric Surgery in the Caribbean: Is It Safe in a Low-Volume, Third World Setting?

Bariatric surgery is a well-recognized modality of management of obesity. In addition to obesity, it effectively controls diabetes mellitus, and hypertension. It has been recommended that bariatric surgery should be done in “designated centers” of excellence where there is a high volume of case turnover. Caribbean nations are not spared from the global spread of the obesity epidemic; however, not many patients get the benefits of bariatric surgery. This study aimed to establish that bariatric surgery could be safely and efficiently undertaken in a low-volume center outside the “designated centers” with comparable patient outcomes even in a third world setting. Though “patient numbers” generally imply better outcome, in an environment where these numbers cannot be achieved, patients should not be denied the access to surgery once good outcomes are achieved

Portal vein thrombosis following laparoscopic cholecystectomy complicated by dengue viral infection: a case report

<p>Abstract</p> <p>Introduction</p> <p>Portal vein thrombosis is an uncommon post-operative complication following abdominal surgery. Although therapeutic anticoagulation is recommended, this treatment may be questionable when the patient has an associated bleeding diathesis.</p> <p>Case presentation</p> <p>We report a case of a 63-year-old woman of Asian Indian ethnicity who developed portal vein thrombosis following an uneventful laparoscopic cholecystectomy for symptomatic gallstones. Her condition was further complicated by dengue viral infection in the post-operative period, with thrombocytopenia immediately preceding the diagnosis of portal vein thrombosis. The etiological connections between dengue viral infection with thrombocytopenia, laparoscopic cholecystectomy, portal vein thrombosis as well as the treatment dilemmas posed in treating a patient with portal vein thrombosis with a bleeding diathesis are discussed.</p> <p>Conclusion</p> <p>When portal vein thrombosis occurs in patients with contraindications to anticoagulation, there is a role for initial conservative management without aggressive anticoagulation therapy and such patients must be approached on an individualized basis.</p

Evaluation of the utilization of the preanaesthetic clinics in a University teaching hospital

BACKGROUND: Dedicated out-patient preanaesthetic clinics are relatively recent phenomenon and information is sparse from developing world. This study attempted to evaluate the utilization of adult and paediatric preanaesthetic clinics and its impact on the cancellations of surgery in Trinidad. METHODS: All patients scheduled to have elective surgery during the period of twelve weeks were enrolled for prospective collection of data including demographics, the admitting diagnoses, surgical procedure, category of surgery and specialty, and the patients' attendance to preanaesthetic clinics. Cancellations on the day of surgery along with reasons were recorded. The difference between patients who attended and did not attend the clinic was analysed. RESULTS: Of 424 patients scheduled for procedures during the study period, 213 were adults and 211 were children. Overall 39% of adults and 46% of the children scheduled for surgery had previously attended the preanaesthetic clinic. Among adults, general surgery patients were the largest majority to attend the preanaesthetic clinic. The paediatric preanaesthetic clinic was mostly utilized by paediatric general surgery. Overall 30% of procedures in adults and 26% of those in children were cancelled. There was a statistically significant difference in cancellations between patients who attended and did not attend the preanaesthetic clinic (p = 0.004). There was a 52% more chance of the procedure getting cancelled if the patient did not attend the clinic. CONCLUSION: The study highlights the inadequate use of the preanaesthetic clinics and the impact of the clinics on last-minute cancellations

Knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in Barbados

BACKGROUND: The aim of the study is to assess the knowledge, attitudes and practices among healthcare professionals in Barbados in relation to healthcare ethics and law in an attempt to assist in guiding their professional conduct and aid in curriculum development. METHODS: A self-administered structured questionnaire about knowledge of healthcare ethics, law and the role of an Ethics Committee in the healthcare system was devised, tested and distributed to all levels of staff at the Queen Elizabeth Hospital in Barbados (a tertiary care teaching hospital) during April and May 2003. RESULTS: The paper analyses 159 responses from doctors and nurses comprising junior doctors, consultants, staff nurses and sisters-in-charge. The frequency with which the respondents encountered ethical or legal problems varied widely from 'daily' to 'yearly'. 52% of senior medical staff and 20% of senior nursing staff knew little of the law pertinent to their work. 11% of the doctors did not know the contents of the Hippocratic Oath whilst a quarter of nurses did not know the Nurses Code. Nuremberg Code and Helsinki Code were known only to a few individuals. 29% of doctors and 37% of nurses had no knowledge of an existing hospital ethics committee. Physicians had a stronger opinion than nurses regarding practice of ethics such as adherence to patients' wishes, confidentiality, paternalism, consent for procedures and treating violent/non-compliant patients (p = 0.01) CONCLUSION: The study highlights the need to identify professionals in the workforce who appear to be indifferent to ethical and legal issues, to devise means to sensitize them to these issues and appropriately training them