70 Improving the Documentation of DNACPR Decisions Following the Transition to Electronic Record Keeping

Background

This quality improvement project was based at The Royal Bolton Hospital across our four Complex Care wards.

Introduction

We have recently transferred to electronic record keeping. At these points of transition there may be an adverse impact on the quality of patient care and safety. We recognised on our own ward there were inaccuracies between the required paper form and electronic documentation of DNACPR decisions. Consequently, we wanted to review and improve the accuracy of our DNACPR documentation to ensure safe and effective patient care.

Methods

To gauge the scope of the problem we audited 87 patient’s electronic and paper notes, with no exclusion criteria. We reviewed whether each patient had a formal resuscitation decision, and if a DNACPR decision had been made whether we met our hospital policy by having:

93% of the 87 patient’s had an active decision regarding resuscitation, with a DNACPR decision documented for 50 patients. Of these 50 patients only 11 had all three forms of documentation. More worryingly, there were discrepancies in the documented DNACPR decisions for 11 patients across paper and electronic records.

Interventions

We escalated our concerns to the Clinical Governance team who sent out a trust wide SBAR highlighting this as an urgent clinical issue. On a directorate level we incorporated DNACPR decision documentation into our afternoon safety huddle and arranged informal teaching for medical, nursing and administrative staff.

Results

Reassuringly, the subsequent re-audit of 90 patient’s notes showed only one patient to have a discrepancy between paper and electronic documentation. We saw an improvement to 98% having paper forms in the right bedside notes and 100% having a documented electronic DNACPR decision.

Conclusion

Through local education and trust-wide dissemination of our expected standards we have seen some improvement. We recognise the importance of maintaining this, and importantly that there is still work to be done. The electronic “Resuscitation and treatment escalation plan” is still rarely completed and provides important information on escalation of care and thus will be the focus of a further educational intervention.

62 A Retrospective Observational Study Into the Correct Administration of Rivaroxaban: Is it Being Taken with Food?

Intro

In July 2019 the MHRA issued a drug safety update reminding healthcare professionals that rivaroxaban should be taken with food. This came after they received a number of thromboembolic events reported in patients prescribed rivaroxaban, thought to be linked with incorrect ingestion on an empty stomach [1].

Our aim was to establish if the healthcare professionals in our department had this knowledge and to audit our current dispensing practice to assess if our hospitalised patient cohort were being exposed to any increased risk.

Methods

A retrospective study was conducted using electronic data from 21 patients that were prescribed rivaroxaban across 14 medical wards. A questionnaire was used to establish the staff’s knowledge.

Results

Of the surveyed healthcare professionals, 79% knew that rivaroxaban should be taken with food (86% of nurses and 79% of doctors). Despite this only 17% of patients took the tablet with food. 75% of patients had rivaroxaban incorrectly dispensed over an hour post meal and 8% were uncertain due to poor documentation. Only 14% of healthcare professionals were aware that in those with swallowing difficulties, rivaroxaban can be crushed.

Conclusions

In our department most of the healthcare professionals had a good academic knowledge of correct rivaroxaban administration, however we have demonstrated that this is failing to correctly influence clinical practice. 75% of patients taking Rivaroxaban in hospital are being subjected to increased risk due to the hospital environment. This was found to relate to the difference in timing of the drug dispensing round in comparison to meal times. As part of the roll out of electronic prescribing in our trust, a warning now shows when both prescribing and dispensing Rivaroxaban to attempt to improve this highlighted risk. We have also highlighted this to the ward managers and at our governance meeting.

Reference

1. Drug Safety Update volume 12, issue 12: July 2019: 3.

Anatomical characterisation of the cricothyroid membrane in females of childbearing age using computed tomography

BACKGROUND

In the event of failure to secure the airway by conventional means, it may be necessary to perform invasive airway access via the cricothyroid membrane. No studies have addressed anatomy of this structure in the obstetric population. We aimed to review the anatomical variation of this structure in a population of childbearing age.

METHODS

We searched the radiology database for computed tomography studies of the neck performed in a 13-month period in consecutive patients aged 15-55 years. Studies on 18 females and 22 males were reviewed. Male patients were included for comparison. Data were reconstructed using a high spatial frequency algorithm to optimise spatial resolution. Five parameters were measured: distance from the skin to the membrane, maximum midline height of the membrane in the vertical plane, maximum transverse diameter of the membrane, neck diameter and cartilaginous calcification.

RESULTS

The distance (mean range) from skin to the membrane was similar in females and males (16.2 [3-33] vs. 13.9 [3-37] mm, P = 0.42). The vertical height (9.9 [7-17] vs. 11.4 [8-15] mm, P = 0.04) and maximum width of the membrane (14.5 [10-17] mm vs. 12.5 [10-15] mm, P < 0.01) were greater in males. Cartilaginous calcification was low and did not differ between genders.

CONCLUSIONS

The cricothyroid membrane is not necessarily a superficial structure and consequently may be difficult to palpate. The smallest dimensions of the membrane indicate that smaller than recommended cricothyroidotomy devices may be required in some patients as the external diameter of commercial trocar devices and tracheal tubes may exceed 7 mm.

Gas-phase detection of trinitrotoluene utilizing a solid-phase antibody immobilized on a gold film by means of surface plasmon resonance spectroscopy

A multilayered biosensor was constructed and found to detect trinitrotoluene (TNT) in ppb concentrations in air both prior to and after detonation of TNT without use of a liquid phosphate buffered saline (PBS) superstrate. The biosensor surface was fabricated from a monoclonal antibody for TNT covalently bound to an 11,11'-dithio-bis(succinimidoylundecanoate) (DSU) self-assembled monolayer immobilized on a thin gold film bonded to a BK7 glass slide. The binding between the immobilized antibody and TNT antigen was detected using surface plasmon resonance spectroscopy (SPRS). Biosensor specificity for TNT was demonstrated with chemical homologues as well as against an unrelated explosive, RDX.

Developmental supervision for nurses

Developmental supervision is gaining increasing recognition in nursing as a form of clinical supervision that will promote professional growth and ultimately lead to improved patient care. Benner's (1984) model of career development is used as a framework in which to examine appropriate forms of supervision for each developmental stage. Directive, collaborative and non-directive supervision are applied to each of these developmental levels.

Regulation of slow wave frequency by IP(3)-sensitive calcium release in the murine small intestine

Slow waves determine frequency and propagation characteristics of contractions in the small intestine, yet little is known about mechanisms of slow wave regulation. We propose a role for intracellular Ca(2+), inositol 1,4,5,-trisphosphate (IP(3))-sensitive Ca(2+) release, and sarcoplasmic reticulum (SR) Ca(2+) content in the regulation of slow wave frequency because 1) 1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid-AM, a cytosolic Ca(2+) chelator, reduced the frequency or abolished the slow waves; 2) thapsigargin and cyclopiazonic acid (CPA), inhibitors of SR Ca(2+)-ATPase, decreased slow wave frequency; 3) xestospongin C, a reversible, membrane-permeable blocker of IP(3)-induced Ca(2+) release, abolished slow wave activity; 4) caffeine and phospholipase C inhibitors (U-73122, neomycin, and 2-nitro-4-carboxyphenyl-N,N-diphenylcarbamate) inhibited slow wave frequency; 5) in the presence of CPA or thapsigargin, stimulation of IP(3) synthesis with carbachol, norepinephrine, or phenylephrine acting on alpha(1)-adrenoceptors initially increased slow wave frequency but thereafter increased the rate of frequency decline, 6) thimerosal, a sensitizing agent of IP(3) receptors increased slow wave frequency, and 7) ryanodine, a selective modulator of Ca(2+)-induced Ca(2+) release, had no effect on slow wave frequency. In summary, these data are consistent with a role of IP(3)-sensitive Ca(2+) release and the rate of SR Ca(2+) refilling in regulation of intestinal slow wave frequency.

The myogenic component in distention-induced peristalsis in the guinea pig small intestine

In an in vitro model for distention-induced peristalsis in the guinea pig small intestine, the electrical activity, intraluminal pressure, and outflow of contents were studied simultaneously to search for evidence of myogenic control activity. Intraluminal distention induced periods of nifedipine-sensitive slow wave activity with superimposed action potentials, alternating with periods of quiescence. Slow waves and associated high intraluminal pressure transients propagated aborally, causing outflow of content. In the proximal small intestine, a frequency gradient of distention-induced slow waves was observed, with a frequency of 19 cycles/min in the first 1 cm and 11 cycles/min 10 cm distally. Intracellular recording revealed that the guinea pig small intestinal musculature, in response to carbachol, generated slow waves with superimposed action potentials, both sensitive to nifedipine. These slow waves also exhibited a frequency gradient. In addition, distention and cholinergic stimulation induced high-frequency membrane potential oscillations (~55 cycles/min) that were not associated with distention-induced peristalsis. Continuous distention produced excitation of the musculature, in part neurally mediated, that resulted in periodic occurrence of bursts of distally propagating nifedipine-sensitive slow waves with superimposed action potentials associated with propagating intraluminal pressure waves that caused pulsatile outflow of content at the slow wave frequency.

Development of interstitial cells of Cajal in a full-term infant without an enteric nervous system

The relationship between the development of the enteric nervous system and interstitial cells of Cajal (ICC) in the human small intestine was investigated in a full-term infant who presented with intestinal pseudo-obstruction. Immunohistochemistry revealed absence of enteric nerves and ganglia but abundant c-Kit immunoreactivity associated with Auerbach's plexus (ICC-AP). However, c-Kit immunoreactivity associated with the deep muscular plexus (ICC-DMP) and intermuscular ICC was absent. Electron microscopy showed ICC-AP with a normal ultrastructure; ICC-DMP were seen but were severely injured, suggesting degeneration. In vitro recording of intestinal muscle showed slow wave activity as well as response to cholinergic stimulation. Fluoroscopic examination of the small bowel showed a variety of motor patterns, including rhythmic, propagating contractions. In conclusion, total absence of enteric nerves was associated with absence of normal ICC-DMP. However, a normal musculature, including a network of ICC-AP, allowed for generation of rhythmic, propagating contractile activity, suggesting the presence of functional motor activity.

Interstitial cells of cajal and inflammation-induced motor dysfunction in the mouse small intestine

BACKGROUND & AIMS

Interstitial cells of Cajal (ICC) play an important role in the control of gastrointestinal motility. We aimed to determine a potential role for ICC in the pathophysiology of inflammation-induced motor disorders.

METHODS

Effects of Trichinella spiralis infection on electrical pacemaker activity, the structure of ICC associated with Auerbach's plexus, and in vivo motor patterns were studied in the mouse small intestine.

RESULTS

Between days 1 and 15 after infection, structural damage occurred in the network of ICC, particularly in the processes connecting ICC to each other and to smooth muscle cells. This was associated with desynchronization of electrical pacemaker activity. Abnormal slow wave activity occurred, including doubling of frequency and electrical quiescence, leading to the development of ectopic pacemaker activity in vivo. In vivo motor patterns in the small intestine changed from consistent peristaltic contractile activity in control animals to periods of quiescence alternating with both orally and aborally propagating contractile activity in the presence of inflammation. Sixty days after infection, all parameters studied had returned to normal values.

CONCLUSIONS

Inflammation-induced alterations in the network of ICC of the small intestine associated with Auerbach's plexus lead to disorganization of motor patterns. Because of the strong temporal correlation between damage to the ICC network, electrical uncoupling, the appearance of ectopic pacemaker activity, and the occurrence of retrograde peristalsis, it is concluded that ICC can play a major role in inflammation-induced motor disturbances.

The effect of extracellular matrix on the growth of mouse olfactory tissue in vitro

The aim of this study was to compare the capacity of extracellular matrix (ECM) components to support the growth and differentiation of olfactory tissue in vitro. Reconstituted basement membrane matrix (RBM) supported profuse neurite outgrowth from explants of olfactory bulb (OB), with no non-neuronal cell migration. In contrast, nasal tissue (NT) explants cultured on RBM produced profuse fibroblastic outgrowth, but no neurite outgrowth from olfactory sensory neurones (OSN). Three-dimensional collagen gels, on the other hand, supported extensive outgrowth of both non-neuronal and neurite outgrowth from OB and NT explants, mature OSNs in the latter being identified using antibodies against olfactory marker protein (OMP). These culture systems represent useful tools for investigating potential tropic influences of target tissue.

Changes in murine jejunal morphology evoked by the bacterial superantigen Staphylococcus aureus enterotoxin B are mediated by CD4+ T cells

Bacterial superantigens (SAgs) are potent T-cell stimuli that have been implicated in the pathophysiology of autoimmune and inflammatory disease. We used Staphylococcus aureus enterotoxin B (SEB) as a model SAg to assess the effects of SAg exposure on gut form and cellularity. BALB/c, SCID (lacking T cells) and T-cell-reconstituted SCID mice were treated with SEB (5 or 100 microg intraperitoneally), and segments of the mid-jejunum were removed 4, 12, or 48 h later and processed for histochemical or immunocytochemical analysis of gut morphology and major histocompatibility complex class II (MHC II) expression and the enumeration of CD3+ T cells and goblet cells. Control mice received saline only. SEB treatment of BALB/c mice caused a time- and dose-dependent enteropathy that was characterized by reduced villus height, increased crypt depth, and a significant increase in MHC II expression. An increase in the number of CD3+ T cells was observed 48 h after exposure to 100 microg of SEB. Enteric structural alterations were not apparent in SEB-treated SCID mice compared to saline-treated SCID mice. In contrast, SEB challenge of SCID mice reconstituted with a mixed lymphocyte population or purified murine CD4+ T cells resulted in enteric histopathological changes reminiscent of those observed in SEB-treated BALB/c mice. These findings implicate CD4+ T cells in this SEB-induced enteropathy. Our results show that SAg immune activation causes significant changes in jejunal villus-crypt architecture and cellularity that are likely to impact on normal physiological processes. We speculate that the elevated MHC II expression and increased number of T cells could allow for enhanced immune responsiveness to other SAgs or environmental antigens.

An outbreak of gentamicin-resistant Klebsiella pneumoniae in a neonatal ward

Gentamicin-resistant Klebsiella pneumoniae (GRKP) was isolated from nineteen patients in the neonatal ward of Sultan Qaboos University Hospital (SQUH) in Oman. Thirteen cases were infected and six were colonized. Two infected patients died due to septicaemia, eight cases occurred within SQUH and eleven cases were imported from other hospitals. Sixteen isolates were of the same serotype (K25), three were non typeable. Referred patients from peripheral hospitals were the source of the organism and hand carriage the probable vehicle of transmission. The first strain of gentamicin-sensitive Kleb. pneumoniae was isolated five months after combating the outbreak.

Transcranial Doppler sonography in headache-free migraineurs

We used transcranial Doppler ultrasonography to determine whether intracranial blood velocities in 182 headache-free migraineurs (60 with aura, 122 without aura) differed from velocities in 38 nonheadache prone control subjects. During the headache-free period, migraineurs with and without aura had significantly elevated mean velocities in all intracranial arteries except the right internal carotid artery at the level of the siphon. Velocities in migraineurs with aura did not differ significantly from velocities in those without aura. Markedly increased velocities were noted in a subset of interictal migraineurs. Two explanations are possible: 1) Blood flow velocities may increase in response to a decrease in the cross sectional area of a vessel at or near the point of insonation. 2) Alterations at the level of the cerebral arteriole may affect regional cerebral blood flow, thereby changing blood flow velocities at the point of insonation. Transcranial Doppler sonography alone cannot sort out which process is responsible for the vascular response. This work may have therapeutic as well as diagnostic implications. When interictal flow velocities are markedly increased, it is possible that therapeutic agents with vasoconstrictor action might cause an excessive response. Further study is needed to clarify the sites of vasoreactivity as well as the magnitude of drug-induced vasoconstrictor response.

Training family practice and internal medicine residents to counsel patients who smoke: improvement and retention of counseling skills

This investigation builds on an earlier study by describing the final results of a training program that teaches internal medicine and family practice residents to counsel patients to stop smoking. In this study, 198 residents participated in a three-hour training program which included small group discussion and role-playing exercises. Videotaped observations of role-playing performances were used to assess behavioral outcomes related to counseling skills for 104 residents who completed pre-, immediate post-, and long-term follow-up testing. The present findings support previous results that show the training program has a significant positive effect on physician smoking cessation counseling skills. A subsample of residents continued to exhibit improved counseling skills one year after the initial educational interventions, suggesting that these skills can be retained over time.

A residents' training program for the development of smoking intervention skills

This article describes the results of a three-hour training program that teaches residents a patient-centered counseling approach to smoking cessation, emphasizing questioning and exploring feelings, rather than providing information. Fifty internal medicine and family practice residents affiliated with a university medical center were assessed before and after training using questionnaires and videotape documenting changes in their knowledge about smoking, attitudes concerning intervention, and intervention skills. The residents showed a significant increase in knowledge and perceived themselves as having significantly more influence on their patients who smoke after completion of the training program. Counseling skills improved significantly in the use of questions and exploring feelings as judged by blind evaluation of videotapes. The results of this three-hour training program suggest that physicians in training are responsive to the teaching of specialized skills deemed important for promoting health behavior changes in their patients.

Benefits and costs of lifestyle change to reduce risk of chronic disease

Individuals do not benefit equally from attempts to change their lifestyles in an effort to lower their risk for disease or to improve their quality of life. A change in one lifestyle behavior may cause an increase in another risk factor and reduce the benefits of the anticipated change. The social environment exerts pressures and makes available resources that also influence the benefits and costs of a particular health behavior change. These pressures and resources vary depending on the individual and his or her social context. This article uses the target behavior of smoking as an example of a lifestyle change and considers the benefits and costs that interventionists need to be aware of if they are to effectively facilitate health behavior change. This approach requires the identification of resources at different levels of the environment (e.g., family, community, institutions) that may influence the cost/benefit ratio. Such an analysis is appropriate whether one is considering a model of individual behavior change or a public health model that seeks to intervene at the community-wide level to promote health and reduce disease risk among a large segment of the population. Specific recommendations based on this approach are offered and it is concluded that both individual and public health approaches are necessary to achieve optimal health behavior change in our population and to optimize the cost/benefit ratio of such change for all individuals.