Hands

Creative writing that explores the abstract side of our profession and our lives.peer-reviewe

Measuring obstetric anaesthesia workload : empirical research using a mixed methods design as part of a quality and safety improvement project

BACKGROUND: Obstetric anaesthetists at Mater Dei Hospital considered the quality and safety of their work was deteriorating due to increasing workload. Literature suggests various ways of measuring this including the delivery rate, caesarian section rate, epidural rate, the obstetric anaesthesia activity index or a combination. The Objectives were: to define the obstetric anaesthesia workload; to benchmark to standards set by international bodies; and to make evidence-based recommendations to improve safety and quality.METHODS: This single-centre study was performed between September 24 and November 20, 2017. It was an empirical research study using a mixed methods design. This allowed for data triangulation. Data was analyzed using SPSS.RESULTS: In 58 days, there were 669 births, 198 (29.6%) of which were by a lower segment Caesarean section (LSCS). On 30 days (52%), elective work over-ran, adding to the on-call workload. Average theatre cases in 24-hours were 3.81 ± 1.55. Epidural rate was 28.4% (n=190). The mean number of epidurals in a 24-hour period was 3.28 ± SD1.609. On 7 days (12%), not all requested epidurals were done because the anaesthetist was busy. Significant 'hidden workload' was identified including patient reviews on 39 days (67%), vascular access outside theatre on 21 days (36%) and stand-by requests on 29 days (50%). There was no statistically significant difference between the work done on weekdays versus weekends.CONCLUSIONS: We identified a significant amount of “hidden workload” in obstetric anaesthesia and workflow inefficiencies. Recommendations are being implemented to increase quality and safety of obstetric anaesthesia in Malta.peer-reviewe

Concordance of gout management with European League against Rheumatism recommendations in hospital practice

Aim: To assess the concordance of gout management with the European League Against Rheumatism (EULAR) gout recommendations in hospital practice. Methods: This was a retrospective review of case notes of patients presenting to rheumatology outpatients between June and December 2009 under the care of 2 consultant rheumatologists. Data collected consisted of demographics, time lag to specialist referral, comorbidities, details about acute and recurrent attacks, lifestyle advice and use of urate lowering therapies. Documented management was assessed for concordance with the EULAR recommendations. Results: Thirty consecutive patients (27 males, 3 females) attending Rheumatology clinic at Mater Dei Hospital were recruited. Mean age at the time of survey was 59.4 ± 10.7 years, while mean age at diagnosis was 51.1 ± 14 years. Documentation of lifestyle advice was recorded for alcohol reduction (83%), weight loss (43%), diet (13%), and exercise (13%). Adequate control of comorbidities was attained in hyperlipidaemia (71%), diabetes mellitus (55%) and hypertension (30%). Advice about smoking cessation was given to 37%. Uric acid levels below target were achieved in 47%. The mean uric acid level at time of survey was 379 ± 146 μmol/l. This was significantly less than that at presentation (p=0.001). Conclusions: Current treatment of gout is poorly concordant with many of the EULAR recommendations. Documentation of lifestyle modifications advice is infrequent except for alcohol reduction. A significant number of patents on allopurinol still have hyperuricaemia implying that more aggressive management is required to improve standard of care. A proforma has been developed to make and help sustain the necessary improvements.peer-reviewe

Obstetric admissions to the Intensive Care Unit in Malta (2012-2015) : a nationwide, population-based, cohort study

Background: To the authors’ knowledge, obstetric admissions to Malta’s ICU have not been studied. Local information was needed to compare with international data. Methods: Patients were recruited retrospectively through the ICU admissions database for 2012 - 2015. Those admitted for obstetric pathology at any stage of pregnancy and up to 30 days postpartum were included in the study. Medical notes were reviewed. Data collected included demographics; obstetric history; admission diagnosis; management including surgery; length of ICU and hospital stay; and maternal and neonatal outcomes. Data was analysed using MS Excel®. Results: 42 obstetric patients were admitted to ICU over the four year period; 39 were included in the study. 0.25% of obstetric deliveries needed admission to ICU and obstetric admissions accounted for 0.87% of all ICU admissions. The commonest admission diagnosis was haemorrhage (62%), followed by hypertensive disorders of pregnancy (26%). All patients had an arterial line inserted and for 33%, this was the only intensive care intervention. 26 patients (67%) required surgery – most commonly, an emergency Lower Segment Caesarian Section (LSCS). There were no maternal deaths over this period. However, four patients miscarried their pregnancy and there were three perinatal deaths. Conclusion: The percentage of deliveries requiring ICU admission in Malta is in line with rates reported in the literature. However, obstetric patients in Malta make up a smaller percentage of all ICU admissions than published rates. The most common admission diagnosis was haemorrhage, in contrast with most studies, where admission was commonly due to hypertensive disorders of pregnancy.peer-reviewe