A quality improvement project using a problem based post take ward round proforma based on the SOAP acronym to improve documentation in acute surgical receiving

Objectives

Ward round documentation provides one of the most important means of communication between healthcare professionals. We aimed to establish if the use of a problem based standardised proforma can improve documentation in acute surgical receiving.

Methods

Gold standards were established using the RCSE record keeping guidelines. We audited documentation for seven days using the following headings: patient name/identification number, subjective findings, objective findings, clinical impression/diagnosis, plan, diet status, discharge decision, discharge planning, signature, and grade.

After the initial audit cycle, a ward round proforma was introduced using the above headings and re-audited over a seven day period.

Results

The pre-intervention arm contained 50 patients and the post intervention arm contained 47. The following headings showed an improvement in documentation compliance to 100%: patient name/identification number vs 96%, subjective findings vs 84%, objective findings vs 48%, plan vs 98%, signature vs 96%, and grade vs 62%. Documentation of the clinical impression/diagnosis improved to 98% vs 30%, diet status rose to 83% vs 16%, discharge decision to 66% vs 16%, and discharge planning to 40% vs 20%.

Conclusions

Standardised proformas improve the documentation of post-take ward round notes. This helps to clarify the onward management plan for all aspects of a patient's care and will help avoid adverse events and litigation. This should improve the quality and safety of Patient Care.

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Proformas improved documentation.

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Clarify management plans.

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Improve patient safety.

Selective cervical nerve root blockade: prospective study of immediate and longer term complications

BACKGROUND AND PURPOSE

Selective cervical nerve root blockade (SCNRB) is a useful procedure for evaluating and treating patients with cervical radiculopathy. Reports of complications related to injections within the cervical nerve root foramen have raised serious doubts regarding the safety of this procedure. This study was performed to prospectively evaluate the safety of fluoroscopically guided outpatient diagnostic and therapeutic SCNRB.

MATERIALS AND METHODS

Eight hundred two consecutive fluoroscopically guided diagnostic and/or therapeutic SCNRBs in 659 patients were performed during a 14-month period (November 2006-December 2007) at affiliated outpatient imaging centers. Each examination was performed by 1 of 8 experienced procedural radiologists by using an anterior oblique approach, with the needle position confirmed with radiographic contrast before injection of an admixture of local anesthetic and steroid. All patients were assessed immediately and at 30 minutes following the procedure. Additionally, 460 patients were called by telephone 30 days following the procedure. All complications were recorded.

RESULTS

Of the 802 attempted procedures, 799 were successfully completed. Three procedures were aborted due to anxiety, challenging body habitus, or persistent venous opacification observed during contrast injection and despite needle repositioning. There were no serious complications, such as stroke, spinal cord insult, permanent nerve root deficit, infection, or significant hematoma. There were 33 minor complications occurring within 30 minutes of the procedure; the most common was vasovagal symptoms. Three hundred forty-five patients were successfully contacted by telephone at 30 days postinjection, 9 of whom reported increased or new pain symptoms.

CONCLUSIONS

With our technique, fluoroscopically guided SCNRB is a safe outpatient procedure with a low immediate and delayed complication rate.

Histology of Sweet Orange Stem Pitting Caused by an Australian Isolate of Citrus tristeza virus

Some strains of the Citrus tristeza virus (CTV) cause stem pitting in sweet orange (Citrus sinensis (L.) Osbeck). This abnormality causes tree decline and reduction in fruit size and yield of affected citrus trees. Stem-pitting symptoms can occur on trunks, on all sizes of limbs, and on the twigs where fruit are produced. Variously sized pits or grooves in the wood often contain a yellow gum. Irregular growth of the phloem occurs in the area of these xylem pits. The histology of stem pitting caused by an Australian CTV isolate was studied in sweet orange using light and electron microscopy. Using scanning electron microscopy, details of the wood pits containing the gumming material were revealed. In thin sections of bark tissue, outgrowths of the phloem tissue were found at various intervals that corresponded to the pits in the wood. Higher numbers of viral inclusions were detected in the phloem outgrowths than were present in the other sieve elements.

The development of the HIV epidemic in Karonga District, Malawi

OBJECTIVE

To investigate the prevalence and sociodemographic risk factors for HIV infection, during the early stages of the epidemic, in a rural area of northern Malawi.

METHODS

As part of a community-based study of mycobacteria, socioeconomic data and HIV results are available on approximately 30,000 individuals from random population samples in 1981-1984 and 1987-1989 from a rural area of Malawi. These have been analysed to characterize the early stages of the HIV epidemic.

RESULTS

The earliest HIV-positive specimens were collected in 1982. HIV prevalence in individuals aged 15-49 years was 0.1% in the early 1980s and 2.0% in the late 1980s. In the early 1980s, eight out of 11 HIV-positive individuals were new immigrants to the district or had recently returned there. In the late 1980s, immigration and having spent time outside the district continued to be major risk factors for HIV. HIV infection was more common in those with occupations other than subsistence farming, in those with more schooling, and in those in the best housing. The association with schooling was seen at all ages for both men and women.

CONCLUSION

Immigration and travel were important in the repeated introduction and establishment of the HIV epidemic. The association with schooling is similar to that found elsewhere in Africa.

No increased prevalence of adrenocortical insufficiency in human immunodeficiency virus-associated tuberculosis

SETTING

Acute medical wards, Kenyatta National Hospital, Nairobi, Kenya.

OBJECTIVE

To determine the prevalence of adrenocortical insufficiency in human immunodeficiency virus (HIV)-1 infected and non-infected patients with tuberculosis.

DESIGN

One hundred and seventy-four patients with proven tuberculosis (90 HIV-1 positive and 84 HIV-1 negative) were assessed for adrenocortical insufficiency with a 30 min synacthen stimulation test.

RESULTS

Fifty-one percent of those with pulmonary tuberculosis and 56% of those with extra-pulmonary tuberculosis had a subnormal cortisol response. However there was no statistically significant difference between the HIV-1 infected and non-infected patients in either group.

CONCLUSION

While an impaired cortisol response is common in tuberculosis, it is no more prevalent in HIV-1 infected patients than non-infected patients with tuberculosis.

Manipulation of glutathione metabolism in transgenic plants

There is clear potential for the genetic manipulation of key enzymes involved in stress metabolism in transgenic plants. However, the data emerging so far from such experiments are equivocal. The detailed analysis of stress responses in progeny of primary transgenics, coupled with comparisons with control transgenic plants that do not contain the GR transgene, allows us to take into account the possible variation in response to stress associated with regeneration of plants from tissue culture. The picture that is now beginning to emerge with respect to the role of GR in stress protection is that, although there are clearly benefits to be had from overexpression of the enzymes, there is no direct correlation between enzyme levels and stress tolerance. It may be that overexpression of the cytosolic isoform (gor2) will prove to be of greater benefit. Furthermore, the types of stresses to which transgenic plants have been exposed in order to assess the consequences of oxidative stress tolerance cannot reproduce those that will experienced in field conditions. Only when plants with higher GR levels and increased glutathione synthesis capacity are grown in field trials will it be possible to make a full assessment of the benefits of engineering plants with altered glutathione metabolism.

Characterisation of isolates and strains of citrus tristeza closterovirus using restriction analysis of the coat protein gene amplified by the polymerase chain reaction

Citrus Tristeza Virus (CTV) exists as a large number of distinct strains differing in biological properties and with different distributions in citrus producing countries. Strategies such as eradication or cross protection, aimed at controlling severe variants of the pathogen, require procedures to identify virus strains accurately and reliably. To fill the need for a rapid, reproducible assay, we have investigated the use of restriction analysis of the CTV coat protein gene amplified using the polymerase chain reaction (PCR). The primers 5' ATG GAC GAC GAA ACA AAG 3' and 5' TCA ACG TGT GTT GAA TTT 3' amplified a DNA copy of the CTV coat protein gene (approx. 670 base pairs) when used in a reverse transcriptase PCR assay. Amplifications were carried out using dsRNA prepared from field and indicator plants, or from single-stranded RNA prepared from crude PEG precipitates of intact virions. All 51 CTV isolates tested produced an amplified product of the same size, regardless of country of origin or biological properties. Digestion of the amplified coat protein genes with the restriction enzymes Hinf1 or Rsa1 revealed sequence variation in the PCR products. Hinf1 provided the best discrimination between strains, defining seven Restriction Fragment Length Polymorphism (RFLP) groups, some of which circumscribed sets of isolates with similar biological properties. Limited analysis of field isolates using this method showed that individual trees could contain mixtures of CTV strains, as assessed by the recovery of several RFLP types from individual reactions. Single aphid transmissions of isolates usually, but not always, generated apparently pure single strains judged by the recovery of single RFLP groups.

Relationship between glutamine concentration and protein synthesis in rat skeletal muscle

Muscle glutamine concentration ([GLN]) and protein synthesis rate (Ks) have been examined in vivo in well-fed, protein-deficient, starved, and endotoxemic rats. With protein deficiency (8 or 5% casein diet), [GLN] fell from 7.70 to 5.58 and 3.56 mmol/kg in the 8 and 5% diet groups, with Ks falling from 15.42 to 9.1 and 6.84%/day. Three-day starvation reduced [GLN] and Ks to 2.38 mmol/kg and 5.6%/day, respectively. In all these groups food intakes and insulin were generally well maintained (except in the starved group), whereas free 3,5,3'-triiodothyronine (T3) was depressed in the starved and 5% protein group. The E. coli lipopolysaccharide endotoxin (3 mg/kg) reduced [GLN] to 5.85 and 4.72 mmol/kg and Ks to 10.5 and 9.10%/day in two well-fed groups. Insulin levels were increased, and free T3 levels fell. Combined protein deficiency and endotoxemia further reduced [GLN] and Ks to 1.88 mmol/kg and 4.01%/day, respectively, in the 5% protein rats. Changes in both ribosomal activity (KRNA) and concentration (RNA/protein) contributed to the fall in Ks in malnutrition and endotoxemia, although reductions in the RNA concentration were most marked with protein deficiency and reductions in the KRNA dominated the response to the endotoxin. The changes in [GLN] and Ks were highly correlated as were [GLN] and both KRNA and the RNA concentration, and these relationships were unique to glutamine. These relationships could reflect sensitivity of glutamine transport and protein synthesis to the same regulatory influences, and the particular roles of insulin and T3 are discussed, as well as any direct influence of glutamine on protein synthesis.

Behaviour of Phytophthora cinnamomi in soils suppressive and conducive to root rot

Suppression of root rot in avocados caused by Phytophthora cinnamomi was demonstrated in soil from a grove at Tamborine Mt., Queensland. The addition of P. cinnamomi inoculum in amounts sufficient to cause severe root rot of plants in other soils, untreated or steam-air treated at 60°C for 30 min, produced little or no damage in the suppressive soil. Suppressive soil was found to have higher populations of bacteria and actinomycetes than soils conducive to root rot. Few sporangia were formed by P. cinnamomi and P. citrophthora in suppressive soil or soil leachate. The suppression of sporangium formation was found to be microbial and not related to the nutrient level of the soil leachate. Mycelium of P. cinnamomi grew through untreated conducive soils, but developed poorly in untreated suppressive soils. The fungus grew readily through all soils steam-air treated at 49, 60 and 100�C for 30 min. After 6 weeks the isolation frequency of P. cinnamomi had declined in the suppressive soil treated at 49 or 60°C for 30 min. Exchangeable calcium and magnesium, nitrogen, and organic matter were higher in soils suppressive to root rot than in conducive soils. Rain-forest soil, where the pathogen is not damaging, was comparable in this respect to the suppressive soil.

Association of bacteria with sporangium formation and breakdown of sporangia in Phytophthora spp

Leachates from different soils extracted at similar moisture potentials varied in their ability to induce sporangium formation, zoospore release and sporangium breakdown in Phytophthora spp. Sporangium production by P. cinnamomi did not occur in soil leachates heated at 40–50°C for 10 min or in soils treated with steam-air at 60° for 30 min. No evidence was obtained that Pseudomonas or Chromobacterium spp. were involved in the induction of sporangium formation. Chemotaxis of bacteria to sporangia occurred at zoospore release. Where sporangial breakdown occurred, the chemotaxis persisted for a longer period as the cytoplasm was withdrawn from the sporangial wall to be released eventually, without zoospore formation, through the papilla. The bacteria were oriented at right angles to the sporangial wall. Electron micrographs showed that in the vicinity of a bacterium, the outer, thin, electron-dense layer of the sporangial wall had disappeared and the cytoplasm of the sporangium had withdrawn from the cell wall.

Bacteria and actinomycetes antagonistic to fungal root pathogens in Australian soils

Techniques are described which make possible the large.scale isolation and screening of potential antagonists to fungal root pathogens. Sixty selected soils from five States have been sampled. Of more than 3500 isolates tested, about 40% inhibited one or more of nine pathogens on agar, and about 4% were effective in soil; a lower percentage might be effective under commercial conditions. Such large. scale methods are essential to success.