Equipment checks reduce errors
EQUIPMENT problems cause a significant proportion of the total errors that occur in operating rooms (OR), and most could be prevented if robust preoperative safety systems were used, according to research published in BMJ Quality and Safety. In a systematic review of the literature on surgical errors and adverse events in the OR, the researchers found the median total errors per procedure were 15.5, and failures of equipment/technology accounted for a median 19.3% of total errors. The median number of equipment problems per procedure was 0.9. The researchers found that when checklists (or similar interventions) were used it reduced equipment error by a mean of 48.6%. “We would therefore recommend the development of a generic checklist system that addresses each of the main categories of equipment problems — availability, configuration and settings, direct malfunctioning/failure — that have been identified in this and previous analyses”, they wrote. “Such a checklist may be carried out relatively seamlessly as an addendum to the current preoperative checks of WHO Surgical Safety Checklist.”

TTEs don’t change clinical care
US research shows that although most transthoracic echocardiograms (TTEs) are appropriate, only one in three resulted in an active change in care and about 21% resulted in no change in care. The retrospective review, published in JAMA Internal Medicine, involved medical records from 535 consecutive TTEs performed at an academic medical centre in 2011. The TTEs were classified according to the 2011 appropriate use criteria (AUC) for echocardiography by two cardiologists blinded to clinical impact, and assessed for clinical impact by two cardiologists blinded to the AUC classification. Clinical impact was assigned to one of three categories — active change in care, continuation of current care (with a documented decision to this effect), or no change in care. Overall, the researchers found that 31.8% of TTEs resulted in an active change in care; 46.9% in continuation of current care; and 21.3% in no change in care. According to 2011 AUC, 91.8% of TTEs were appropriate; 4.3% were inappropriate; and 3.9% uncertain. “We detected no statistically significant difference between appropriate and inappropriate TTEs in the proportion of TTEs that led to active change in care (32.2% vs 21.7%)”, the researchers wrote. “The discrepancy between appropriateness and clinical impact is striking and suggests that the AUC as currently implemented are unlikely to facilitate optimal use of TTE. Given the importance of responsible use of limited medical resources and the need to control increasing health care costs, additional research into the necessity of TTE in the process of medical care is needed and will require collaboration among hospitals, administrators, politicians, economists, the government, and patients.”

Stay on statins to avoid Parkinson’s
AN evaluation of Chinese patients taking statins has found an association between discontinuation of statin use and the incidence of Parkinson disease (PD). The research, published in Neurology, found that, among 43 810 people who started taking statins, those who continued to take lipophilic statins had a decreased incidence of PD when compared those who discontinued them. The association was strongest for simvastatin and atorvastatin, after adjusting for age, sex, comorbidities and other potential confounder medications. The potential beneficial effect was not observed in users of hydrophilic statins. The incidence rate for PD was 1.68 and 3.52 per 1 000 000 person-days for those taking lipophilic and hydrophilic statins, respectively. The researchers said that as PD was a neurodegenerative disorder with a long presymptomatic period, there could be a window of opportunity to modify the disease process before the onset of motor symptoms. “In this context, we speculated that lipophilic statins may act through modifying the level or sensitivity of dopamine receptors in striatum, rather than holding the neuronal degeneration process”, they wrote. An accompanying editorial said current data provided some “compelling evidence” that the benefits of statins extended beyond antihyperlipid therapeutic effects. “For those who have to be on statins, it is a comforting thought that there is a potential added advantage of having a lower risk of PD, and possibly other neurologic disorders as well”, the editorial said.

Cardiac benefits of breakfast
A LARGE prospective analysis of eating habits and coronary heart disease (CHD) in middle-aged and older US men has found an increased risk of CHD among those who skipped breakfast and who regularly ate late at night. The research, published in Circulation, involved the eating habits of 26 902 American men aged 45–82 years from the Health Professionals Follow-up Study who were assessed in 1992 as free of cardiovascular disease and cancer. During 16 years of follow-up, 1527 incident CHD cases were diagnosed. Men who skipped breakfast had a 27% higher risk of CHD compared with men who did not, and men who ate late at night had a 55% higher CHD risk than those who did not. No association was observed with eating frequency (times per day). “Our study is the first to assess eating habits in relation to CHD, and the associations we report are significant but modest, requiring replication”, the researchers wrote. “If replicated in women and other ethno-cultural groups, the findings from the present study provide evidence to support a recommendation of daily breakfast eating by clinicians and health authorities to prevent CHD and to improve health at both the individual and population levels.”

Tick bite anaphylaxis under recognised
AUSTRALIAN researchers have called for increased awareness and guidelines for tick bite management in tick-endemic areas after finding cases of anaphylaxis among emergency presentations of tick bites. The research, published in Emergency Medicine Australasia, reported on 566 cases of tick bites presenting to a single Sydney hospital over a 2-year period, of which 34 cases (6%) resulted in anaphylaxis. The researchers found cutaneous symptoms were the most common feature associated with anaphylaxis (32/34, 94%); other symptoms included hypotension and/or tachycardia (9/34; 26%) and dyspnoea, wheezing or chest tightness (20/34; 59%). About 40% (13/34) of anaphylaxis patients had a history of allergy or previous anaphylaxis, with 76% (26/34) administered adrenaline either before presenting or in the ED and 97% (33/34) treated with steroids. Fifty-three per cent were referred to an immunologist and only a quarter were discharged with an adrenaline auto-injector. The researchers said the variation in patient management could reflect under-recognition of the true incidence of tick bite anaphylaxis. “The present study highlights not only the incidence of tick bite allergy and anaphylaxis, but also the variation in its emergency management, prevention and follow up”, they wrote.

Mentors key in reducing readmissions
A PROJECT involving cooperation between multiple hospitals has had minor success in reducing readmissions in older patients. The research, published in the Journal of Hospital Medicine, involved Project BOOST (Better Outcomes for Older adults through Safe Transitions), which recruited a diverse national cohort of academic and non-academic hospitals in the US to participate in quality improvement by implementing best practices for hospital discharge care transitions. The project used a national collaboration facilitated by external expert mentors. The researchers found the average rate of 30-day rehospitalisation among the 11 BOOST hospitals was 14.7% before the project was implemented and 12.7% after. In 19 matched control hospitals rehospitalisation rates were 14.0% and 14.1% for the same period. The mean absolute reduction in readmission rates over the 1-year study period in BOOST hospitals compared to control units was 2.0%. Length of stay in BOOST hospitals decreased by an average 0.5 days compared with 0.3 days in control hospitals. “Among the insights gained from this pilot experience, and incorporated into ongoing BOOST cohorts, is the importance of intensive mentor engagement to foster accountability among participant sites, assist with implementation troubleshooting, and offer expertise that is often particularly effective in gaining local support”, the researchers wrote. “We now encourage sites to have 2 mentor site visits to further these roles and more frequent conference calls.”

Draft PSA test summary released
THE NHMRC has released a draft summary for medical practitioners on the harms and benefits of prostate-specific antigen (PSA) testing for prostate cancer in asymptomatic men. PSA testing for prostate cancer in asymptomatic men: information for health practitioners provides a summary of the evidence. “By providing balanced information on both the potential benefits and harms of PSA testing in asymptomatic men, the document aims to assist health practitioners in their discussions with men and their families”, the NHMRC website says. As well as providing evidence on harms and benefits, the document answers a series of common questions such as the accuracy of the PSA test. The NHMRC has invited submissions on the draft document, which close on 20 August.


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