Regular performance feedback may be key to maintain good quality DKA management: results from a five-year study

OBJECTIVES

We postulate that performance feedback is a prerequisite to ensure sustained improvement in diabetic ketoacidosis (DKA) management.

DESIGN

The study was based on 'theory of change' concept that suggests changes of primary drivers determine the main outcome. A set of secondary drivers can be implemented to achieve improvements in these primary drivers and thus the main outcome.

SETTING

This study was conducted at a large tertiary care center in the West Midlands, UK. The region has above average prevalence of diabetes and DKA admissions in the country.

PARTICIPANTS

All participants diagnosed with DKA as per national guidelines, except those managed in intensive care unit from April 2014 to March 2018, were included in this study.

INTERVENTIONS

Monthly feedback of performance was the main intervention. Development of a real-time live DKA audit tool, automatic referral system of DKA to the specialist team, electronic monitoring of blood gas measurements and education and redesigning of local (trust) guidelines were the other interventions in this study.

MAIN OUTCOME MEASURES

Total DKA duration, appropriateness of fixed rate intravenous insulin infusion, fluid prescription, glucose monitoring, ketone monitoring and referral to specialists.

RESULTS

There was a significant reduction in the duration of DKA postintervention compared with baseline results. However, in the absence of regular feedback, the duration of DKA showed an upward trend nearing baseline values. Similar trends were noted in secondary drivers influencing DKA duration.

CONCLUSION

Based on these results, we recommend regular audit and feedback is required to sustain improvements in DKA management.

Medical reconnaissance for the Defence Medical Services Dhaulagiri Expedition 2016

The formation of a clear and well-informed medical plan is critical to the safe planning and execution of any expedition in remote locations. We performed a reconnaissance of medical facilities in Nepal in March 2015 prior to a large Defence Medical Services (DMS) expedition to the Dhaulagiri area in 2016. Visiting relevant medical facilities in person provides invaluable information and experience of what healthcare services may be relied upon in managing an expedition casualty, in scenarios ranging from minor illness to major trauma. We describe the principles, practice and level of detail required for performing such a medical reconnaissance and illustrate this with examples of our findings from Nepal.

Double-echo three-point-Dixon method for fat suppression MRI

A double-echo two-excitation pulse sequence encoding fat and water signals for a phase-sensitive three-point Dixon-type analysis (DE-3PD) was developed and implemented on a 1.5 T MR imager. Data processing was performed using a previously developed two-dimensional (2D) region-growing algorithm, adapted to use double-echo data. Density-, T1-, and T2-weighted fat suppression images were obtained from six volunteers using the new fat suppression method. The images were compared with corresponding images obtained using frequency-selective excitation fat suppression (FATSAT) and a single-echo three-point-Dixon method (SE-3PD). The results demonstrate that the DE-3PD sequence shortens the imaging time by one-third compared with the SE-3PD method, without loss in image quality. The data also show that a 2D region-growing algorithm effectively unwraps the phase of DE-3PD data sets, and that results of DE-3PD fat signal suppression are consistently better than those obtained using a standard FATSAT method. The authors conclude that the double-echo sequence provides density-, T1-, and T2-weighted images that appear to be promising for routine clinical applications.

Coronary arteriography performed by a physician assistant

Funding constraints and an oversupply of cardiologists mitigate against continued training of increasing numbers of cardiology fellows. In some institutions, the workload of the catheterization laboratory is an overriding factor. The ability of a physician assistant to perform some of this work was tested to determine if the number of fellows and the content of the fellowship training program could be uncoupled from the catheterization laboratory workload. Among the first 150 patients in whom coronary arteriography was performed by a physician assistant, no patient died or had a myocardial infarction or stroke. Two patients (1.3%) had minor complications: a retinal embolus and an infected puncture site. The complication rate in 150 consecutive cases performed by fellows was also 1.3%, a small myocardial infarction and a transient ischemic attack. Procedure times for the physician assistant and for the fellows were 41 +/- 13 and 44 +/- 18 minutes for preoperative patients and 62 +/- 24 and 70 +/- 20 minutes for postoperative patients. Corresponding fluoroscopy times were 11 +/- 5 and 12 +/- 7 minutes for the preoperative and 22 +/- 12 and 20 +/- 6 for postoperative patients. Only preoperative fluoroscopy times were statistically different (p = 0.02). Thus, substituting a physician assistant for a fellow to perform coronary arteriography is an option in institutions at which the number of studies exceeds the training needs of fellows.