Search results for: acute care surgery

Authors: Diane Ghanem, Whitney Kagabo, Rebecca Engels, Uma Srikumaran, Babar Shafiq

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Hospitalist co-management of orthopaedic surgery patients is a growing trend across the country. It was created as a collaborative effort to provide overarching care to patients with the goal of improving their postoperative care and decreasing in-hospital medical complications. The aim of this project is to provide a guide for implementing and optimizing a hospitalist co-management service in orthopaedic surgery. Key leaders from the hospitalist team, orthopaedic team and quality, safety and service team were identified. Multiple meetings were convened to discuss the comanagement service and determine the necessary building blocks behind an efficient and well-designed co-management framework. After meticulous deliberation, a consensus was reached on the final service agreement and a written guide was drafted. Fundamental features of the service include the identification of service stakeholders and leaders, frequent consensus meetings, a well-defined framework, with goals, program metrics and unified commands, and a regular satisfaction assessment to update and improve the program. Identified pearls for co-managing orthopaedic surgery patients are standardization, timing, adequate patient selection, and two-way feedback between hospitalists and orthopaedic surgeons to optimize the protocols. Developing a service agreement is a constant work in progress, with meetings, discussions, revisions, and multiple piloting attempts before implementation. It is a partnership created to provide hospitals with a streamlined admission process where at-risk patients are identified early, and patient care is optimized regardless of the number or nature of medical comorbidities. A wellestablished hospitalist co-management service can increase patient care quality and safety, as well as health care value.

Keywords: co-management, hospitalist co-management, implementation, orthopaedic surgery, quality improvement

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Authors: Md. Shakhawat Hossain, Jimma Hossain, Md. Naushad Ali

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Acute pancreatitis is a dangerous medical emergency in the practice of gastroenterology. Management of acute pancreatitis needs multidisciplinary approach with support starts from emergency to ICU. So, there is a chance of mismanagement in every steps, especially in low resource settings. Other factors such as patient’s financial condition, education, social custom, transport facility, referral system from periphery may also challenge the current guidelines for management. The present study is intended to determine the clinico-pathological profile, severity assessment and challenges of management of acute pancreatitis in a government laid tertiary care hospital to image the real scenario of management in a low resource place. A total 100 patients of acute pancreatitis were studied in this prospective study, held in the Department of Gastroenterology, Rangpur medical college hospital, Bangladesh from July 2017 to July 2018 within one year. Regarding severity, 85 % of the patients were mild, whereas 13 were moderately severe, and 2 had severe acute pancreatitis according to the revised Atlanta criteria. The most common etiologies of acute pancreatitis in our study were gall stone (15%) and biliary sludge (15%), whereas 54% were idiopathic. The most common challenges we faced were delay in hospital admission (59%) and delay in hospital diagnosis (20%). Others are non-adherence of patient party, and lack of investigation facility, physician’s poor knowledge about current guidelines. We were able to give early aggressive fluid to only 18% of patients as per current guideline. Conclusion: Management of acute pancreatitis as per guideline is challenging when optimum facility is lacking. So, modified guidelines for assessment and management of acute pancreatitis should be prepared for low resource setting.

Keywords: acute pancreatitis, challenges of management, severity, prognosis

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Authors: Elena Ivany, Leanne Aitken

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Little is known about the delivery of end-of-life care in cardiac intensive care unit (CICU) settings. The aims of this study were to highlight the nurse-identified barriers and facilitators to delivering end-of-life care in the CICU, and to identify whether any of the barriers and/or facilitators are specific to the CICU setting. This was an exploratory qualitative study utilizing semi-structured individual interviews as the data collection method and inductive thematic analysis to structure the data. Six CICU nurses took part in the study. Five key themes were identified, each theme including both barriers and facilitators. The five key themes are as follows: patient-centered care, emotional challenges, reaching concordance, nursing contribution and the surgical intensive care unit.

Keywords: end-of-life, cardiovascular disease, cardiac surgery, critical care

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Authors: Liong-Rung Liu, Yu-Hui Chiu, Wen-Han Chang

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Firearm injuries are high-energy injuries. The ballistic pathways could cause severe burns or chemical damages to vessels, musculoskeletal or other major organs. The high mortality rate is accompanied by complications such as sepsis. As laws prohibit gun possession, civilian gunshot wounds (GSW) are relatively rare in Taiwan. Our hospital, Mackay Memorial Hospital, located at the center of Taipei city is surrounded by nightclubs and red-light districts. Due to this unique location, our hospital becomes the first-line trauma center managing gunshot victims in Taiwan. To author’s best knowledge, there are few published research articles regarding this unique situation. We hereby analyze the distinct characteristics and length of stay (LOS) of GSW patients in the emergency room (ER) at Mackay Memorial Hospital. A 6-year retrospective analysis of 27 patients treated for GSW injuries from January 2012 to December 2017 was performed. The patients’ records were reviewed for the following analyses, 1) wound position and the correlated clinical presentations; 2) the LOS in ED of patients receiving emergency surgery for major organ or vascular injuries. We found males (96.3%) were injured by guns more often than females (3.7%) in all age groups. The most common injured site was in the extremities. With regards to the ER LOS, the average time were 72.2 ± 34.5 minutes for patients with triage I and 207.4 ± 143.9 minutes for patients with triage II. The ED LOS of patients whose ISS score were more than 15 was 59.9 ± 25.6 minutes, and 179.4 ± 119.8 minutes for patients whose ISS score were between 9 to 15, respectively. Among these 27 patients, 10 patients had emergency surgery and their average ED stay time was 104.5 ± 33.3 minutes. Even more, the average ED stay time could be shortened to 88.8 ± 32.3 minutes in the 5 patients with trauma team activation. In conclusion, trauma team activation in severe GSW patients indeed shortens the ED LOS and might initially improve the quality of patient care. This is the result of better trauma systems, including advances in care from emergency medical services and acute care surgical management.

Keywords: gunshot, length of stay, trauma, mortality

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Authors: Maha Salah, Hanaa Hashem, Mahmoud M. Alsagheir, Mohammed Salah

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Acute respiratory distress syndrome (ARDS) represents a complex clinical syndrome and carries a high risk for mortality. The severity of the clinical course, the uncertainty of the outcome, and the reliance on the full spectrum of critical care resources for treatment mean that the entire health care team is challenged. Researchers and clinicians have investigated the nature of the pathological process and explored treatment options with the goal of improving outcome. Through this application of research to practice, we know that some previous strategies have been ineffective, and innovations in mechanical ventilation, sedation, nutrition, and pharmacological intervention remain important research initiatives. Developed Clinical pathway is multidisciplinary plans of best clinical practice for this specified groups of patients that aid in the coordination and delivery of high quality care. They are a documented sequence of clinical interventions that help a patient to move, progressively through a clinical experience to a desired outcome. Although there is a lot of heterogeneity in patients with ARDS, this suggested developed clinical pathway with alternatives was built depended on a lot of researches and evidence based medicine and nursing practices which may be helping these patients to improve outcomes, quality of life and decrease mortality.

Keywords: acute respiratory distress syndrome (ARDS), clinical pathway, clinical syndrome

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Authors: O. Davies, K. Veravalli, P. Panwalkar, M. Tofighi, P. Butterick, B. Healy, A. Mofidi

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Vancomycin resistant enterococcus infection is a condition that usually impacts ICUs, transplant, dialysis, and cancer units, often as a nosocomial infection. After an outbreak in the acute trauma and orthopaedic unit in Morriston hospital, we aimed to access the conditions that predispose VRE infections in our unit. Thirteen cases of VRE infection and five cases of VRE colonisations were identified in patients who were treated for orthopaedic care between 1/1/2020 and 1/11/2021. Cases were reviewed to identify predisposing factors, specifically looking at age, presenting condition and treatment, presence of infection and antibiotic care, active haemo-oncological condition, long term renal dialysis, previous hospitalisation, VRE predisposition, and clearance (PREVENT) scores, and outcome of care. The presenting condition, treatment, presence of postoperative infection, VRE scores, age was compared between colonised and the infected cohort. VRE type in both colonised and infection group was Enterococcus Faecium in all but one patient. The colonised group had the same age (T=0.6 P>0.05) and sex (2=0.115, p=0.74), presenting condition and treatment which consisted of peri-femoral fixation or arthroplasty in all patients. The infected group had one case of myelodysplasia and four cases of chronic renal failure requiring dialysis. All of the infected patient had sustained an infected complication of their fracture fixation or arthroplasty requiring reoperation and antibiotics. The infected group had an average VRE predisposition score of 8.5 versus the score of 3 in the colonised group (F=36, p<0.001). PREVENT score was 7 in the infected group and 2 in the colonised group(F=153, p<0.001). Six patients(55%) succumbed to their infection, and one VRE infection resulted in limb loss. In the orthopaedic cohort, VRE infection is a nosocomial condition that has peri-femoral predilection and is seen in association with immunosuppression or renal failure. The VRE infection cohort has been treated for infective complication of original surgery weeks prior to VRE infection. Based on our findings, we advise avoidance of infective complications, change of practice in use of antibiotics and use radical surgery and surveillance for VRE infections beyond infective precautions. PREVENT score shows that the infected group are unlikely to clear their VRE in the future but not the colonised group.

Keywords: surgical site infection, enterococcus, orthopaedic surgery, vancomycin resistance

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Authors: Joshua Chew, Vesa Cheng, David Thomson

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Background: Hereditary angioedema (HAE) or C1 esterase deficiency is a relatively rare entity that has a potential for significant anesthetic complications. Methods: A literature review was performed of published cases of surgery in patients with HAE. Results were limited to English language only and cases were examined for management strategies and successful prevention of acute attacks. Results: The literature revealed the successful use of C1 esterase inhibitors as the most common agent in surgical prophylaxis therapy. Other therapeutic targets described included kallikrein inhibitors and bradykinin B2 receptor antagonists. Conclusions: Therapeutic targets that exist for the management of acute attacks in HAE have been successfully employed in the setting of surgery. The data is currently limited and could not be used as a firm evidence base, but the limited outcomes seen are positive and reassuring for the prospective anesthetic management of this potentially fatal condition.

Keywords: anesthesia, C1 esterase deficiency, hereditary angioedema, surgical prophylaxis

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Authors: Novita Verayanti Manalu, Alvin Salim

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Background: Palliative care is caring holistically for patients and families to improve their quality of life. Experts stated that palliative care could be applied not only for terminally ill cases but also for acute illnesses. Therefore, this study wants to find out the level of knowledge about palliative care of the nurses along with the relationship with attitude and performance. Method: This study applies a cross-sectional survey design and allows the respondents to fill two questionnaires to determine the level of knowledge and attitude toward palliative care, while one questionnaire is filled out by the head nurse to evaluate nurses’ performance. The relationship was analyzed by Spearman rho’s correlation in alpha < 0,05 by SPSS. Results: The majority of respondents were females, aged above 25 years old, and married. Most of the nurses are staff nurses and the ratio of education level is not significantly different. The knowledge level is poor, while the attitude and performance are at an adequate level. Knowledge may affect attitude, but it doesn’t happen toward performance. Conclusion: There is a need for increased knowledge about palliative care to improve attitude and work performance. Future researchers might use this finding as a reference to conduct further study in improving knowledge of palliative care.

Keywords: knowledge, attitude, work performance, palliative care

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Authors: Areej Makeineldein Mustafa

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The study evaluates the management processes and healthcare provider compliance with the National Institute for Health and Care Excellence recommendations for constipation management. We aimed to evaluate the adherence to National Institute for Health and Care Excellence guidelines in the management of constipation during the period from February to June 2023. We collected data from a random sample ( 51 patients) over 4 months with inclusion criteria for patients above 60 who were just admitted to the care of the elderly department during this period. Patient age, sex, medical records for constipation, acute or chronic constipation, or opioid-induced constipation, and treatment options were used to identify constipation and the type of treatment given. Our findings indicate that there is a gap between practice and National Institute for Health and Care Excellence guideline steps; only 3 patient was given medications according to National Institute for Health and Care Excellence guidelines in order of combination or steps of escalation. Addressing these gaps could potentially lead to enhanced patient outcomes and an overall improvement in the quality of care provided to individuals suffering from constipation.

Keywords: constipation, elderly, management, patient

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Authors: Pei-Ru Yang, Yu-Chen Lin, Jia-Min Wu

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Background: A 58-year-old man with a history of osteoporosis and diabetes presented with chronic pain in his left knee due to severe knee joint degeneration. The knee replacement surgery was recommended by the doctor. But the patient suffered from low pain tolerance and wondered if virtual reality could relieve acute postoperative wound pain. Methods: We used the PICO (patient, intervention, comparison, and outcome) approach to generate indexed keywords and searched systematic review articles from 2017 to 2021 on the Cochran Library, PubMed, and Clinical Key databases. Results: The initial literature results included 38 articles, including 12 Cochrane library articles and 26 PubMed articles. One article was selected for further analysis after removing duplicates and off-topic articles. The eight trials included in this article were published between 2013 and 2019 and recruited a total of 723 participants. The studies, conducted in India, Lebanon, Iran, South Korea, Spain, and China, included adults who underwent hemorrhoidectomy, dental surgery, craniotomy or spine surgery, episiotomy repair, and knee surgery, with a mean age (24.1 ± 4.1 to 73.3 ± 6.5). Virtual reality is an emerging non-drug postoperative analgesia method. The findings showed that pain control was reduced by a mean of 1.48 points (95% CI: -2.02 to -0.95, p-value < 0.0001) in minor surgery and 0.32 points in major surgery (95% CI: -0.53 to -0.11, p-value < 0.03), and the overall postoperative satisfaction has improved. Discussion: Postoperative pain is a common clinical problem in surgical patients. Research has confirmed that virtual reality can create an immersive interactive environment, communicate with patients, and effectively relieve postoperative pain. However, virtual reality requires the purchase of hardware and software and other related computer equipment, and its high cost is a disadvantage. We selected the best literature based on clinical questions to answer the patient's question and used share decision making (SDM) to help the patient make decisions based on the clinical situation after knee replacement surgery to improve the quality of patient-centered care.

Keywords: knee replacement surgery, postoperative pain, share decision making, virtual reality

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Authors: Yun-Tsuen Chen, Shih-Ting Huang, Pi-Fen Cheng, Heng-Hua Wang, Hui-Zhu Chen

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This paper discusses the experience of caring for a patient diagnosed with breast cancer and later received total mastectomy during a 2nd trimester pregnancy. She was hospitalized from January 31 to February 4, 2018. Using 'Gordon’s 11 Functional Health Patterns' through physical exams and interviews, the researcher assessed the patient’s physical and mental health and determined the patient to have anxiety, acute pain, and body image disturbance. After establishing a strong relationship with the patient, the researcher helped the patient express her anxiety and personal feelings. A multi-specialist team was formed to evaluate both the patient and her unborn child, before, during, and after surgery. This individualized care allowed the patient and her child to optimize the post-operative results. Aside from medication, the patient also received non-medicinal treatment, including improvement of sleep quality with body positioning, diaphragmatic breathing exercises for pain and stress relief after surgery. Throughout hospitalization, the patient’s physical and emotional needs were addressed daily with listening sessions and empathy. The patient’s husband was also incorporated in the patient’s recovery by teaching both he and the patient how to change the sterile wound dressing, which may have the added benefit of improving marital relationships through shared activities of nurturing. The patient was also given advice about how to improve self-confidence through clothing. Lastly, the patient was encouraged to join a support group for breast cancer patients. Through the sharing of experience in groups and within the family, the patient was helped to adapt to the change of her appearance and re-establish her self-confidence. This level of care expedited the patient’s return to her family life and role of being a mother.

Keywords: anxiety, body image disturbance, breast cancer during pregnancy, multi-specialist team

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Authors: Hyuk-Hoon Kim, Young Gi Min

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Background: Acute poisoning is the common cause of morbidity and mortality. Characteristics of acute poisoning differ between countries. While other countries operate the database system for poisoning, Korea has not collected the database for acute poisoning. Distribution of incidence of acute poisoning depending on the types of materials have also not studied in Korea. Our aims are to evaluate the etiologic and demographic characteristics of acute poisoning cases and to obtain up-to-date information on acute poisonings. Method: We retrospectively recorded cases of acute poisoning from eight emergency departments of second level or university hospitals from different cities in Gyeonggi province in Korea from April 2006 and March 2015. The distributions of incidence of acute poisoning depending on the types of materials are mapped by geographic information system. Result: A total of 3,449 poisoned cases were analyzed. Mean estimated age of patients was 39.56 ± 22.40 years. Mean male to female ratio of patients was 1:1.4. Mean proportion of intentional poisoning was 57.9%. Common materials are benzodiazepine (16.6%), carbon monoxide (10.5%), pesticide (8.1%) and zolpidem (7.1%) Common route of exposure is ingestion (79.5%) and followed by inhalation (16.5%). Common treatment methods are gastric lavage (20%) and activated charcoal (30%). Most cases had uneventful recovery; 61.4% were treated as outpatients and 0.1% of the poisoning resulted in death in ER. Conclusion: Even though the cases enrolled in our study is not the overall cases of acute poisoning in Korea, our study could be the basis of countermeasures for analysis and prevention of acute poisoning in Korea.

Keywords: acute poisoning, emergency department, epidemiology, Korea

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Authors: Ali Chitgar

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Respiratory infections including diseases in camels are important not only because of the threat of animal health but also to reduce their production. Since that deal with respiratory problems and their treatment requires adequate knowledge of the existing respiratory problems, unfortunately, there is limited information about the species of camels. This study aimed to identify lung lesions camels slaughtered in a slaughterhouse more important was performed using histopathology. Respiratory camels (n = 477) was examined after the killing fully and tissue samples were placed in 10% formalin. The samples and histological sections using hematoxylin and eosin staining and color were evaluated. In this study 79.6 % (236 of 477 samples) of the samples was at least a lung lesion. Rate acute interstitial pneumonia, chronic interstitial pneumonia, bronchopneumonia, bronchiolitis, an inflammation of the pleura and 52.8 % respectively atelectasis (236 of 477 samples), 5.4 % (24 of 477 samples), 7.8 % (35 of 477 samples), 6.7 % (30 of 477 samples), 3.4 % (15 of 477 samples) and 15.2% (68 of 477 samples). The lung lesions, acute interstitial pneumonia and bronchopneumonia in autumn winter rather than spring and summer (p <0/05) and as a result, this study showed that high rates of lung lesions in the camel population. Waste higher results in cold seasons (fall and winter) shows.

Keywords: camel, surgery, histopathology, breathing organ

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Authors: Aline Giardin, Ana Fontoura, Thomas Anderson

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Transsexuality is a condition that requires the work of professionals from various fields for diagnosis and treatment. The correct diagnosis is very important because the surgery is irreversible. Diagnostic elements are essentially clinical and an observation period of two years prior to surgery is recommended. In this review article, we discuss the importance of psychiatric nursing for the care of transgender patients, as well as their mental health. Transsexuality is a phenomenon that contrasts our common understandings of sexuality, but it is not a sexual issue. Also called gender dysphoria is a mismatch between the anatomical sex of an individual and their gender identity. In relation to mental health, among transsexuals, we find variations ranging from psychoses to total normality. As the etiology is still controversial, there is no biological marker and only the clinical criteria can be used. Portaria nº 2803, of November 19, 2013, Brazil, regulates the surgical reassignment of sex by the SUS and the nurse started to work also in operational groups (transsexuals who wish to perform surgery and other procedures of reassignment of sex). Health and education, establishes links and guides the care that female and male transsexual patients will have to have before and after surgery. It is also important to say that the work of health education is not only concerned with aspects related to the sexual reassignment surgery, but also with the mental health of its patients and with the family. One of the main complaints of patients is the impression that professionals seem to find them strange and feel extremely uncomfortable when they talk about their desire to undergo sex-change surgery: Investigate the role of nursing in the process of change sexual. Our methodology was a review of articles produced between 1994 and 2015. It was concluded that nursing should specialize for this new demand, which is growing more and more in our health services. We believe that nursing is specializing to enter this context and the expectations are good for the professionals and for the reception of the transsexual patient.

Keywords: transex, nursing, importance, patient

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Authors: Salman Imran, Chris Healey

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Traditionally, medical care of children in England and Wales starts from primary care with a referral to secondary care paediatricians who may not investigate further. Many primary care doctors do not undergo a paediatric rotation/exposure in training. As a result, there are many who have not acquired the necessary skills to manage children hence increasing hospital referral. With the current demand on hospitals in the National Health Service managing more problems in the community is needed. One way of handling this is to set up clinics, meetings and huddles in GP surgeries where professionals involved (general practitioner, paediatrician, health visitor, community nurse, dietician, school nurse) come together and share information which can help improve communication and care. The increased awareness and education that paediatricians can impart in this way will help boost confidence for primary care professionals to be able to be more self-sufficient. This has been tried successfully in other regions e.g., St. Mary’s Hospital in London but is crucial for a more rural setting like ours. The primary aim of this project would be to educate specifically GP’s and generally all other health professionals involved. Additional benefits would be providing care nearer home, increasing patient’s confidence in their local surgery, improving communication and reducing unnecessary patient flow to already stretched hospital resources. Methods: This was done as a plan do study act cycle (PDSA). Three clinics were delivered in different practices over six months where feedback from staff and patients was collected. Designated time for teaching/discussion was used which involved some cases from the actual clinics. Both new and follow up patients were included. Two clinics were conducted by a paediatrician and nurse whilst the 3rd involved paediatrician and local doctor. The distance from hospital to clinics varied from two miles to 22 miles approximately. All equipment used was provided by primary care. Results: A total of 30 patients were seen. All patients found the location convenient as it was nearer than the hospital. 70-90% clearly understood the reason for a change in venue. 95% agreed to the importance of their local doctor being involved in their care. 20% needed to be seen in the hospital for further investigations. Patients felt this to be a more personalised, in-depth, friendly and polite experience. Local physicians felt this to be a more relaxed, familiar and local experience for their patients and they managed to get immediate feedback regarding their own clinical management. 90% felt they gained important learning from the discussion time and the paediatrician also learned about their understanding and gaps in knowledge/focus areas. 80% felt this time was valuable for targeted learning. Equipment, information technology, and office space could be improved for the smooth running of any future clinics. Conclusion: The acute paediatric outpatient clinic can be successfully established in primary care facilities. Careful patient selection and adequate facilities are important. We have demonstrated a further step in the reduction of patient flow to hospitals and upskilling primary care health professionals. This service is expected to become more efficient with experience.

Keywords: clinics, education, paediatricians, primary care

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Authors: Abdul-Ganiyu Fuseini, Bernice Redley, Helen Rawson, Lenore Lay, Debra Kerr

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Aim: The study aimed to develop and validate a culturally appropriate patient-reported outcome measure for measuring dignity for older adults during acute hospital admissions. Design: A three-phased mixed-method sequential exploratory design was used. Methods: Concept elicitation and generation of items for the scale was informed by older adults’ perspectives about dignity during acute hospitalization and a literature review. Content validity evaluation and pre-testing were undertaken using standard instrument development techniques. A cross-sectional survey design was conducted involving 270 hospitalized older adults for evaluation of construct and convergent validity, internal consistency reliability, and test–retest reliability of the scale. Analysis was performed using Statistical Package for the Social Sciences, version 25. Reporting of the study was guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. Results: We established the 15-item Hospitalized Older Adults’ Dignity Scale that has a 5-factor structure: Shared Decision-Making (3 items); Healthcare Professional-Patient Communication (3 items); Patient Autonomy (4 items); Patient Privacy (2 items); and Respectful Care (3 items). Excellent content validity, adequate construct and convergent validity, acceptable internal consistency reliability, and good test-retest reliability were demonstrated. Conclusion: We established the Hospitalized Older Adults Dignity Scale as a valid and reliable scale to measure dignity for older adults during acute hospital admissions. Future studies using confirmatory factor analysis are needed to corroborate the dimensionality of the factor structure and external validity of the scale. Routine use of the scale may provide information that informs the development of strategies to improve dignity-related care in the future. Impact: The development and validation of the Hospitalized Older Adults Dignity Scale will provide healthcare professionals with a feasible and reliable scale for measuring older adults’ dignity during acute hospitalization. Routine use of the scale may enable the capturing and incorporation of older patients’ perspectives about their healthcare experience and provide information that informs the development of strategies to improve dignity-related care in the future.

Keywords: dignity, older adults, hospitalisation, scale, patients, dignified care, acute care

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Authors: Minna K. Miller, Chantel. E. Canessa, Suzanna V. McRae, Susan Shumay, Alissa Collingridge

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Primary care provides the first point of contact and access to health care services. For the pediatric population, the goal is to help healthy children stay healthy and to help those that are sick get better. Primary care facilitates regular well baby/child visits; health promotion and disease prevention; investigation, diagnosis and management of acute and chronic illnesses; health education; both consultation and collaboration with, and referral to other health care professionals. There is a protective association between regular well-child visit care and preventable hospitalization. Further, low adherence to well-child care and poor continuity of care are independently associated with increased risk of hospitalization. With a declining number of family physicians caring for children, and only a portion of pediatricians providing primary care services, it is becoming increasingly difficult for children and their families to access primary care. Nurse practitioners are in a unique position to improve access to primary care and improve health outcomes for children. Limited literature is available on the nurse practitioner role in primary care pediatrics. The purpose of this paper is to describe the development, implementation and evaluation of a Nurse Practitioner-led pediatric primary care clinic in a tertiary care setting. Utilizing the participatory, evidence-based, patient-focused process for advanced practice nursing (PEPPA framework), this paper highlights the results of the initial needs assessment/gap analysis, the new service delivery model, populations served, and outcome measures.

Keywords: access, health outcomes, nurse practitioner, pediatric primary care, PEPPA framework

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Authors: A. Haddick, A. Soltan

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Background: During the period of recovery from an operative obstetric procedure, a woman is not only at risk of the life-threatening complications accompanying labour but also those associated with surgery and anaesthesia. It is speculated that women in the recovery area may receive a lower standard of care over a night shift. Thus obstetric recovery room care should be evaluated regularly to ensure all women receive an equally high standard of care 24/7. Aim: The aim of this audit was to undertake an audit in the Liverpool Women’s Hospital on the care in recovery, and to ascertain the extent to which the standards were met. This audit included the full audit cycle. Method: Standards were taken from the AAGBI, RCOA, NICE and CNST guidelines. There were 12 standards including appropriate documentation of vital signs and appropriate length of stay after surgery. Notes from 100 patients were analysed from March 2011-March 2012. There were 52 day notes and 48 night notes; these were accessed to gain the relevant data. In the re audit 35 notes were accessed from March 14-September 14. Results: The Liverpool Women’s Hospital met in total 10 of these standards. 10 were met during the day shift (83%) and 0 met during the night shift. In the re audit, there was a significant improvement in the standards met at night. 9 of the standards were met during the day and 7 of the standards were met at night. Clearly there are still improvements to be made. Conclusions: In the original audit, an audit action plan was formulated. This was following discussion of the results of this audit in an MDT meeting and presentation with a consultant Obstetrician, the head of Midwifery, the head of Obstetrics theatres and a recovery nurse. This audit will be further discussed in the Liverpool Woman's Hospital in July 2015 for further implementation for improvement.

Keywords: care, recovery, room, women

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Authors: Kristel Dame Bañez Sumagaysay, Marie Victoria Cruz-javier

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The current subject is a case of a 21 year-old woman at 29 1/7 weeks of gestation with Pre-B cell Acute Lymphoblastic Leukemia who was admitted to the coronary care unit (CCU) of the St. Luke’s Medical Center-Global City for Severe Acute Respiratory Distress Syndrome (ARDS) secondary to hospital-acquired pneumonia secondary to pneumocystis jiroveci; central line-associated bloodstream infection (E. aerogenes). She presented with chronic hypoxemia caused by Pulmonary edema, probably secondary to heart failure secondary to cardiomyopathy chemotherapy-induced. Due to worsening feto-maternal status, extracorporeal membrane oxygenation (ECMO) for respiratory support was instituted, and an elective cesarean section was done due to multiple maternal factors and deteriorating health status under total intravenous anesthesia assisted by veno-venous extracorporeal membrane oxygenation. She delivered a live preterm newborn male, APGAR Score: 1, 0, 0, birth weight 985 grams, birth length: 40.5cm, small for gestational age.

Keywords: extracorporeal membrane oxygenation, pre-b cell acute lymphoblastic leukemia, severe acute respiratory distress syndrome, ethical dilemmas

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Authors: Rawan Masarwa, Merav Ben Natan, Yaron Berkovich

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Background: Hip fracture repair surgery carries a certain mortality risk, yet evidence suggests that orthopedic surgeons often refrain from discussing this issue with patients prior to surgery. Aim: This study aims to examine whether orthopedic surgeons address the issue of one-year post-surgery mortality before hip fracture repair surgery and to explore the factors influencing this decision. Method: The study uses a cross-sectional design, administering validated digital questionnaires to 150 orthopedic surgeons. Results: A minority of orthopedic surgeons reported consistently informing patients about the risk of mortality in the year following hip fracture surgery. The primary reasons for not discussing this risk were a desire to avoid frightening patients, time constraints, and concerns about undermining patient hope. Surgeons reported a medium-high level of perceived self-efficacy, with higher self-efficacy linked to a reduced likelihood of discussing one-year mortality risk. In contrast, older age and holding a specialist status in orthopedic surgery were associated with a higher likelihood of discussing this risk with patients. Conclusions: The findings suggest a need for interventions to address communication barriers and ensure consistent provision of essential information to patients undergoing hip fracture surgery. Additionally, they emphasize the importance of considering individual factors such as self-efficacy, age, and expertise in developing strategies to enhance patient-provider communication in orthopedic care settings.

Keywords: orthopedic surgeons, hip fracture surgery, mortality risk communication, patient information

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Authors: Bency Ann Massinello, Nancy Day, Janet Fellini

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Background: The use of an appropriate mode of communication among the multidisciplinary care team members regarding coordination of care is an extremely complicated yet important patient safety initiative. Effective communication among the team members(nursing staff, medical staff, respiratory therapists, rehabilitation therapists, patient-family services team…) become essential to develop a culture of trust and collaboration to deliver the highest quality care to patients are their families. The inpatient post-acute pediatrics, where children and their caregivers come for continuity of care, is no exceptions to the increasing use of text messages as a means to communication among clinicians. One such platform is the Vocera Communications (Vocera Smart Mobile App called Vocera Edge) allows the teams to use the application and share sensitive patient information through an encrypted platform using IOS company provided shared and assigned mobile devices. Objective: This paper discusses the quality initiative of implementing the transition from Vocera Smartbage to Vocera Edge Mobile App, technology advantage, use case expansion, and lessons learned about a secure alternative modality that allows sending and receiving secure text messages in a pediatric post-acute setting using an IOS device. This implementation process included all direct care staff, ancillary teams, and administrative teams on the clinical units. Methods: Our institution launched this transition from voice prompted hands-free Vocera Smartbage to Vocera Edge mobile based app for secure care team texting using a big bang approach during the first PDSA cycle. The pre and post implementation data was gathered using a qualitative survey of about 500 multidisciplinary team members to determine the ease of use of the application and its efficiency in care coordination. The technology was further expanded in its use by implementing clinical alerts and alarms notification using middleware integration with patient monitoring (Masimo) and life safety (Nurse call) systems. Additional use of the smart mobile iPhone use include pushing out apps like Lexicomp and Up to Date to have it readily available for users for evident-based practice in medication and disease management. Results: Successful implementation of the communication system in a shared and assigned model with all of the multidisciplinary teams in our pediatric post-acute setting. In just a 3-monthperiod post implementation, we noticed a 14% increase from 7,993 messages in 6 days in December 2020 to 9,116messages in March 2021. This confirmed that all clinical and non-clinical teams were using this mode of communication for coordinating the care for their patients. System generated data analytics used in addition to the pre and post implementation staff survey for process evaluation. Conclusion: A secure texting option using a mobile device is a safe and efficient mode for care team communication and collaboration using technology in real time. This allows for the settings like post-acute pediatric care areas to be in line with the widespread use of mobile apps and technology in our mainstream healthcare.

Keywords: nursing informatics, mobile secure texting, multidisciplinary communication, pediatrics post acute care

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Authors: K. Bensafia, A. Mansour, G. Le Maillot, B. Clement, O. Reynet, P. Ariès, S. Haddab

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This paper presents a system designed for wireless acquisition, the recording of electrocardiogram (ECG) signals and the monitoring of the heart’s health during surgery. This wireless recording system allows us to visualize and monitor the state of the heart’s health during a surgery, even if the patient is moved from the operating theater to post anesthesia care unit. The acquired signal is transmitted via a Bluetooth unit to a PC where the data are displayed, stored and processed. To test the reliability of our system, a comparison between ECG signals processed by a conventional ECG monitoring system (Datex-Ohmeda) and by our wireless system is made. The comparison is based on the shape of the ECG signal, the duration of the QRS complex, the P and T waves, as well as the position of the ST segments with respect to the isoelectric line. The proposed system is presented and discussed. The results have confirmed that the use of Bluetooth during surgery does not affect the devices used and vice versa. Pre- and post-processing steps are briefly discussed. Experimental results are also provided.

Keywords: electrocardiography, monitoring, surgery, wireless system

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Authors: Aamna Tufail, Kajal Kotecha, Iordanis Toursounidis, Ravinder Pabla

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Introduction/Aims: Acute Myeloid Leukaemia (AML) is a part of leukaemic group of hematopoietic disorders with a varying range of presentations, including oro-facial manifestations. Early recognition and management are essential for favourable outcomes. Materials and Methods: We present our experience, clinical presentation, and clinical photographs of a patient with previously undiagnosed AML who presented with oral symptoms to the emergency department of our hospital. An analysis of clinical characteristics, diagnostic investigations, and management modalities was performed. Results/Statistics: A 58-year-old man presented to A&E reporting an 11-day history of right sided facial swelling, acute TMJ symptoms, and oral discomfort. A dentist ruled out acute dental causes one day post onset of symptoms. Initial assessment was anatomically inconsistent and did not reveal a routine oral or maxillofacial etiology. Detailed clinical examination demonstrated fever, generalised pallor, swelling and erythema of right nasolabial region, bilateral masseteric tenderness, intraoral palatal ecchymosis, palatal ulceration, buccal and labial petechiae, cervical lymphadenopathy, and haematoma on dorsum of right hand overlying right 2nd metacarpal joint. Suspecting a systemic medical cause, we requested haematological investigations, which revealed neutropenia, thrombocytopenia, and anaemia. Flow cytometry confirmed CD34 + AML. Oral discomfort was managed symptomatically. The patient was referred to a tertiary care centre for acute haematologic care, where he was treated with IV antibiotics and continuing cycles of chemotherapy. Conclusions/Clinical Relevance: Oro-facial manifestations may be the first clinical sign of AML. Awareness of its features is vital in early diagnosis. In this context, dentists and oral medicine specialists can play an important role in detecting clinical signs of haematological disorders such as AML.

Keywords: acute myeloid leukaemia, oral symptoms, ulceration, diagnosis, management

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Authors: Bill D. Geis

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Suicide wrongful death forensic cases are the fastest rising tort in mental health law. It is estimated that suicide-related cases have accounted for 15% of U.S. malpractice claims since 2006. Most suicide-related personal injury claims fall into the legal category of “wrongful death.” Though mental health experts may be called on to address a range of forensic questions in wrongful death cases, the central consultation that most experts provide is about the negligence element—specifically, the issue of whether the clinician met the clinical standard of care in assessing, treating, and managing the deceased person’s mental health care. Standards of care, varying from U.S. state to state, are broad and address what a reasonable clinician might do in a similar circumstance. This fact leaves the issue of the suicide standard of care, in each case, up to forensic experts to put forth a reasoned estimate of what the standard of care should have been in the specific case under litigation. Because the general state guidelines for standard of care are broad, forensic experts are readily retained to provide scientific and clinical opinions about whether or not a clinician met the standard of care in their suicide assessment, treatment, and management of the case. In the past and in much of current practice, the assessment of suicide has centered on the elicitation of verbalized suicide ideation. Research in recent years, however, has indicated that the majority of persons who end their lives do not say they are suicidal at their last medical or psychiatric contact. Near-term risk assessment—that goes beyond verbalized suicide ideation—is needed. Our previous research employed structural equation modeling to predict lethal suicide risk--eight negative thought patterns (feeling like a burden on others, hopelessness, self-hatred, etc.) mediated by nine transdiagnostic clinical factors (mental torment, insomnia, substance abuse, PTSD intrusions, etc.) were combined to predict acute lethal suicide risk. This structural equation model, the Lethal Suicide Risk Pattern (LSRP), Acute model, had excellent goodness-of-fit [χ2(df) = 94.25(47)***, CFI = .98, RMSEA = .05, .90CI = .03-.06, p(RMSEA = .05) = .63. AIC = 340.25, ***p < .001.]. A further SEQ analysis was completed for this paper, adding a measure of Acute Suicide Ideation to the previous SEQ. Acceptable prediction model fit was no longer achieved [χ2(df) = 3.571, CFI > .953, RMSEA = .075, .90% CI = .065-.085, AIC = 529.550].This finding suggests that, in this additional study, immediate verbalized suicide ideation information was unhelpful in the assessment of lethal risk. The LSRP and other dynamic, near-term risk models (such as the Acute Suicide Affective Disorder Model and the Suicide Crisis Syndrome Model)—going beyond elicited suicide ideation—need to be incorporated into current clinical suicide assessment training. Without this training, the standard of care for suicide assessment is out of sync with current research—an emerging dilemma for the forensic evaluation of suicide wrongful death cases.

Keywords: forensic evaluation, standard of care, suicide, suicide assessment, wrongful death

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Authors: Barun K. De

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Acquired immunodeficiency syndrome (AIDS) is caused by two types of human immunodeficiency viruses, collectively designated HIV. HIV infection is spreading globally particularly in developing countries. Before an individual is diagnosed with HIV, the disease goes through different phases. First there is an acute early phase that is followed by an established or chronic phase. Subsequently, there is a latency period after which the individual becomes immunodeficient. It is in the acute phase that an individual is highly infectious due to a high viral load. Presently, HIV diagnosis involves use of tests that do not detect the acute phase infection during which both the viral RNA and p24 antigen are expressed. Instead, these less sensitive tests detect antibodies to viral antigens which are typically sero-converted later in the disease process following acute infection. These antibodies are detected in both asymptomatic HIV-infected individuals as well as AIDS patients. Studies indicate that early diagnosis and treatment of HIV infection can reduce medical costs, improve survival, and reduce spreading of infection to new uninfected partners. Newer 4th generation combination antigen/antibody tests are highly sensitive and specific for detection of acute and established HIV infection (HIV1 and HIV2) enabling immediate linkage to care. The CDC (Center of Disease Control, USA) recently recommended an algorithm involving three different tests to screen and diagnose acute and established infections of HIV-1 and HIV-2 in a general population. Initially a 4th generation combo test detects a viral antigen p24 and specific antibodies against HIV -1 and HIV-2 envelope proteins. If the test is positive it is followed by a second test known as a differentiation assay which detects antibodies against specific HIV-1 and HIV-2 envelope proteins confirming established infection of HIV-1 or HIV-2. However if it is negative then another test is performed that measures viral load confirming an acute HIV-1 infection. Screening results of a Phoenix area population detected 0.3% new HIV infections among which 32.4% were acute cases. Studies in the U.S. indicate that this algorithm effectively reduces HIV infection through immediate treatment and education following diagnosis.

Keywords: new algorithm, HIV, diagnosis, infection

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Authors: Hansraj Bookun, Angela Tan, Rachel Xuan, Linheng Zhao, Kejia Wang, Animesh Singla, David Kim, Christopher Loupos

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Introduction: Incisional wound complications in vascular surgery patients represent a significant clinical and econometric burden of morbidity and mortality. The objective of this study was to trial the feasibility of applying the Prevena negative pressure incision management system as a routine dressing in patients who had undergone arterial surgery. Conventionally, Prevena has been applied to groin incisions, but this study features applications on multiple wound sites such as the thigh or major amputation stumps. Method: This was a cross-sectional observational, single-centre case series of 12 patients who had undergone major vascular surgery. Their wounds were managed with the Prevena system being applied either intra-operatively or on the first post-operative day. Demographic and operative details were collated as well as the length of stay and complication rates. Results: There were 9 males (75%) with mean age of 66 years and the comorbid burden was as follows: ischaemic heart disease (92%), diabetes (42%), hypertension (100%), stage 4 or greater kidney impairment (17%) and current or ex-smoking (83%). The main indications were acute ischaemia (33%), claudication (25%), and gangrene (17%). There were single instances of an occluded popliteal artery aneurysm, diabetic foot infection, and rest pain. The majority of patients (50%) had hybrid operations with iliofemoral endarterectomies, patch arterioplasties, and further peripheral endovascular treatment. There were 4 complex arterial bypass operations and 2 major amputations. The mean length of stay was 17 ± 10 days, with a range of 4 to 35 days. A single complication, in the form of a lymphocoele, was encountered in the context of an iliofemoral endarterectomy and patch arterioplasty. This was managed conservatively. There were no deaths. Discussion: The Prevena wound management system shows that in conjunction with safe vascular surgery, absolute wound complication rates remain low and that it remains a valuable adjunct in the treatment of vasculopaths.

Keywords: wound care, negative pressure, vascular surgery, closed incision

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Authors: Naim Izet Kajtazi

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Context: Increased intracranial pressure and associated symptoms such as headache, papilledema, motor or sensory deficits, seizures, and conscious disturbance are well-known in acute CVT. However, visual loss is not commonly associated with this disease, except in the case of secondary IIH associated with it. Process: We report a case of a 40-year-old male with Behçet’s disease and cerebral venous thrombosis, and other multiple comorbidities admitted with a four-day history of increasing headache and rapidly progressive visual loss bilaterally. The neurological examination was positive for bilateral papilledema of grade 3 with light perception on the left eye and counting fingers on the right eye. Brain imaging showed old findings of cerebral venous thrombosis without any intraparenchymal lesions to suggest a flare-up of Behçet’s disease. The lumbar puncture, followed by the lumbar drain insertion, gave no benefit in headache or vision. However, he completely lost sight. The right optic nerve sheath fenestration did not result in vision improvement. The acute spinal shock complicated the lumbar drain removal due to epidural hematoma. An urgent lumbar laminectomy with hematoma evacuation undertook. Intra-operatively, the neurosurgeon noted suspicious abnormal vessels at conus medullaris with the possibility of an arteriovenous malformation. Outcome: In a few days following the spinal surgery, the patient vision started to improve. Further improvement was achieved after plasma exchange sessions followed by cyclophosphamide. In the recent follow-up in the clinic, he reported better vision, drove, and completed his Ph.D. studies. Relevance: Visual loss in patients with Behçet’s disease should always be anticipated and taken reasonable care of, ensuring that they receive well-combined immunosuppression with anticoagulation and agents to reduce intracranial pressure. This patient’s story is significant for a high disease burden and complicated hospital course by acute spinal shock due to spinal lumbar drain removal with a possible underlying spinal arteriovenous malformation.

Keywords: Behcet disease, optic neuritis, IIH, CVT

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Authors: Maha Salah Abdullah Ismail, Mahmoud M. Alsagheir, Mohammed Salah Abd Allah

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Acute respiratory distress syndrome (ARDS) is characterized by permeability pulmonary edema and refractory hypoxemia. Lung-protective ventilation is still the key of better outcome in ARDS. Prone position reduces the trans-pulmonary pressure gradient, recruiting collapsed regions of the lung without increasing airway pressure or hyperinflation. Prone ventilation showed improved oxygenation and improved outcomes in severe hypoxemic patients with ARDS. This study evaluates the effect of prone positioning on mechanically ventilated patients with ARDS. A quasi-experimental design was carried out at Critical Care Units, on 60 patients. Two tools were utilized to collect data; Socio demographic, medical and clinical outcomes data sheet. Results of the present study indicated that prone position improves oxygenation in patients with severe respiratory distress syndrome. The study recommended that use prone position in patients with severe ARDS, as early as possible and for long sessions. Also, replication of this study on larger probability sample at the different geographical location is highly recommended.

Keywords: acute respiratory distress syndrome, critical care, mechanical ventilation, prone position

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Authors: Theo Welch

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Background: Gamma-hydroxybutyrate (GHB) is a depressant of the central nervous system with euphoric effects. It is being increasingly used recreationally in the United Kingdom (UK) despite associated morbidity and mortality. Due to the lack of evidence, healthcare professionals remain unsure as to the optimum management of GHB acute toxicity. Methods: A literature review was undertaken of its pharmacology and the emergency management of its acute toxicity.Findings: GHB is inexpensive and readily available over the Internet. Treatment of GHB acute toxicity is supportive. Clinicians should pay particular attention to the airway as emesis is common. Intubation is required in a minority of cases. Polydrug use is common and worsens prognosis. Conclusion: An inexpensive and readily available drug, GHB acute toxicity can be difficult to identify and treat. GHB acute toxicity is generally treated conservatively. Further research is needed to ascertain the indications, benefits, and risks of intubating patients with GHB acute toxicity. instructions give you guidelines for preparing papers for the conference.

Keywords: GHB, gamma-hydroxybutyrate, prehospital, emergency, toxicity, management

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Authors: Jamal Abdi

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This paper is largely a response/critique of Samuel P. Huntington´s Clash of Civilizations thesis. The overriding argument is that Huntington´s thesis is characterized by failure to distinguish between ´groups´ and ´categories´. Multinational civilizations overcoming their internal collective action problems, which would enable them to pursue a unified strategy vis-à-vis the West, is a rather foundational assumption in his theory. Without assigning sufficient intellectual attention to the processes through which multinational civilizations may gain capacity for concerted action i.e. become a group, he contended that the post-cold-war world would be shaped in large measure by interactions among seven or eight major civilizations. Thus, failure in providing a convincing analysis of multi-national civilizations´ transition from categories to groups is a significant weakness in Huntington´s clash theory. It is also suggested that so-called Islamic terrorism and the war on terror is not to be taken as an expression of presence of clash between a Western and an Islamic civilization, as terrorist organizations would be superfluous in a world characterized by clash of civilizations. Consequences of multinational civilizations becoming a group are discussed in relation to contemporary Western superiority.

Keywords: categories, civilizations, clash, groups, groupness

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