Arthur Vleugels

The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: Analysis of administrative data

BACKGROUND In most multicenter studies that examine the relationship between nurse staffing and patient safety, nurse-staffing levels are measured per hospital. This can obscure relationships between staffing and outcomes at the unit level and lead to invalid inferences. OBJECTIVE In the present study, we examined the association between nurse-staffing levels in nursing units that treat postoperative cardiac surgery patients and the in-hospital mortality of these patients. DESIGN-SETTING-PARTICIPANTS: We illustrated our approach by using administrative databases (Year 2003) representing all Belgian cardiac centers (n=28), which included data from 58 intensive care and 75 general nursing units and 9054 patients. METHODS We used multilevel logistic regression models and controlled for differences in patient characteristics, nursing care intensity, and cardiac procedural volume. RESULTS Increased nurse staffing in postoperative general nursing units was significantly associated with decreased mortality. Nurse staffing in postoperative intensive care units was not significantly associated with in-hospital mortality possibly due to lack of variation in ICU staffing across hospitals. CONCLUSION This study, together with the international body of evidence, suggests that nurse staffing is one of several variables influencing patient safety. These findings further suggest the need to study the impact of nurse-staffing levels on in-hospital mortality using nursing-unit-level specific data.

Ionic currents during hypoxia in voltage-clamped cat ventricular muscle.

To explore the mechanisms underlying the shortening of the cardiac action potential in hypoxia, we studied the effect of hypoxia on the ionic currents in cat papillary and trabecular muscles using the single sucrose gap-voltage clamp technique. For potentials positive to −70 mV, hypoxia induces an increase in time-independent outward current. The changes in the tail current suggest that time-dependent outward current is not increased but, rather, reduced. Because the time course of IK remains unchanged, we concluded that the shortening of the action potential is not a result of a change in the time-dependent outward current. In the potential range of the plateau, the amplitude of the slow inward current is not affected by hypoxia. Its time constant of inactivation appears slightly decreased. The prolongation of the action potential by epinephrine during hypoxia is accompanied by an increase in the slow inward current. As a result of these studies, we conclude that the shortening of the cardiac action potential in the early stage of hypoxia results from an increase in K+outward background current. Circ Res 47: 501-508, 1980

Health Care Professionals as Second Victims after Adverse Events A Systematic Review

Adverse events within health care settings can lead to two victims. The first victim is the patient and family and the second victim is the involved health care professional. The latter is the focus of this review. The objectives are to determine definitions of this concept, research the prevalence and the impact of the adverse event on the second victim, and the used coping strategies. Therefore a literature research was performed by using a three-step search procedure. A total of 32 research articles and 9 nonresearch articles were identified. The second victim phenomenon was first described by Wu in 2000. In 2009, Scott et al. introduced a detailed definition of second victims. The prevalence of second victims after an adverse event varied from 10.4% up to 43.3%. Common reactions can be emotional, cognitive, and behavioral. The coping strategies used by second victims have an impact on their patients, colleagues, and themselves. After the adverse event, defensive as well as constructive changes have been reported in practice. The second victim phenomenon has a significant impact on clinicians, colleagues, and subsequent patients. Because of this broad impact it is important to offer support for second victims. When an adverse event occurs, it is critical that support networks are in place to protect both the patient and involved health care providers.

Nurse staffing and patient outcomes in Belgian acute hospitals: Cross-sectional analysis of administrative data

BACKGROUND Studies have linked nurse staffing levels (number and skill mix) to several nurse-sensitive patient outcomes. However, evidence from European countries has been limited. OBJECTIVES This study examines the association between nurse staffing levels (i.e. acuity-adjusted Nursing Hours per Patient Day, the proportion of registered nurses with a Bachelors degree) and 10 different patient outcomes potentially sensitive to nursing care. DESIGN-SETTING-PARTICIPANTS: Cross-sectional analyses of linked data from the Belgian Nursing Minimum Dataset (general acute care and intensive care nursing units: n=1403) and Belgian Hospital Discharge Dataset (general, orthopedic and vascular surgery patients: n=260,923) of the year 2003 from all acute hospitals (n=115). METHODS Logistic regression analyses, estimated by using a Generalized Estimation Equation Model, were used to study the association between nurse staffing and patient outcomes. RESULTS The mean acuity-adjusted Nursing Hours per Patient Day in Belgian hospitals was 2.62 (S.D.=0.29). The variability in patient outcome rates between hospitals is considerable. The inter-quartile ranges for the 10 patient outcomes go from 0.35 for Deep Venous Thrombosis to 3.77 for failure-to-rescue. No significant association was found between the acuity-adjusted Nursing Hours per Patient Day, proportion of registered nurses with a Bachelors degree and the selected patient outcomes. CONCLUSION The absence of associations between hospital-level nurse staffing measures and patient outcomes should not be inferred as implying that nurse staffing does not have an impact on patient outcomes in Belgian hospitals. To better understand the dynamics of the nurse staffing and patient outcomes relationship in acute hospitals, further analyses (i.e. nursing unit level analyses) of these and other outcomes are recommended, in addition to inclusion of other study variables, including data about nursing practice environments in hospitals.

Supporting involved health care professionals (second victims) following an adverse health event: A literature review

BACKGROUND One out of seven patients is involved in an adverse event. The first priority after such an event is the patient and their family (first victim). However the involved health care professionals can also become victims in the sense that they are traumatized after the event (second victim). They can experience significant personal and professional distress. Second victims use different coping strategies in the aftermath of an adverse event, which can have a significant impact on clinicians, colleagues, and subsequent the patients. It is estimated that nearly half of health care providers experience the impact as a second victim at least once in their career. Because of this broad impact it is important to offer support. OBJECTIVE The focus of this review is to identify supportive interventional strategies for second victims. STUDY DESIGN An extensive search was conducted in the electronic databases Medline, Embase and Cinahl. We searched from the start data of each database until September 2010. RESULTS A total of 21 research articles and 10 non-research articles were identified in this literature review. There are numerous supportive actions for second victims described in the literature. Strategies included support organized at the individual, organizational, national or international level. A common intervention identified support for the health care provider to be rendered immediately. Strategies on organizational level can be separated into programs specifically aimed at second victims and more comprehensive programs that include support for all individuals involved in the adverse event including the patient, their family, the health care providers, and the organization. CONCLUSION Second victim support is needed to care for health care workers and to improve quality of care. Support can be provided at the individual and organizational level. Programs need to include support provided immediately post adverse event as well as on middle long and long term basis.

Hypoxia increases potassium efflux from mammalian myocardium

Hypoxia with or without simultaneous depletion of extracellular glucose increases42K-efflux in cat and guinea-pig papillary muscles and bovine Purkinje fibres. The change observed in K efflux may be the result of an increase in K conductance at rest.

Incidence and outcome of inappropriate in-hospital empiric antibiotics for severe infection: a systematic review and meta-analysis.

IntroductionThe aims of this study were to explore the incidence of in-hospital inappropriate empiric antibiotic use in patients with severe infection and to identify its relationship with patient outcomes.MethodsMedline (from 2004 to 2014) was systematically searched by using predefined inclusion criteria. Reference lists of retrieved articles were screened for additional relevant studies. The systematic review included original articles reporting a quantitative measure of the association between the use of (in)appropriate empiric antibiotics in patients with severe in-hospital infections and their outcomes. A meta-analysis, using a random-effects model, was conducted to quantify the effect on mortality by using risk ratios.ResultsIn total, 27 individual articles fulfilled the inclusion criteria. The percentage of inappropriate empiric antibiotic use ranged from 14.1% to 78.9% (Q1-Q3: 28.1% to 57.8%); 13 of 27 studies (48.1%) described an incidence of 50% or more. A meta-analysis for 30-day mortality and in-hospital mortality showed risk ratios of 0.71 (95% confidence interval 0.62 to 0.82) and 0.67 (95% confidence interval 0.56 to 0.80), respectively. Studies with outcome parameter 28-day and 60-day mortality reported significantly (P ≤0.02) higher mortality rates in patients receiving inappropriate antibiotics. Two studies assessed the total costs, which were significantly higher in both studies (P ≤0.01).ConclusionsThis systematic review with meta-analysis provides evidence that inappropriate use of empiric antibiotics increases 30-day and in-hospital mortality in patients with a severe infection.

Electrophysiological effects of aprindine on isolated heart preparations.

Abstract The electrophysiological effects of aprindine, a new anti-arrhythmic drug, were investigated in isolated cardiac tissues of different animals. Diastolic depolarization and spontaneous firing were attenuated or abolished by aprindine. The action potential duration and effective refractory period were markedly shortened in Purkinje fibres. At the same concentrations, the action potential duration in atrial and ventricular muscle was not significantly altered. Membrane responsiveness curve was shifted to a more negative membrane potential. At concentrations above 5 mg/l, Purkinje fibres became inexcitable. Uptake and release of 14C-aprindine was studied in isolated heart preparations. Equilibration was not reached after an incubation period of 60 min and a final concentration of 10 times the concentration in the uptake fluid was attained after 60 min. The long-lasting effects on transmembrane potentials could be explained by the slow release of 14C-aprindine. A large fraction of the 14C-aprindine content was released with a time constant of 3 hr. The mechanism responsible for the in vivo anti-arrhythmic action and side effects are discussed.

Differential effects of hypoxia with age on the chick embryonic heart. Changes in membrane potential, intracellular K and Na, K efflux and glycogen.

SummaryThe effects of hypoxia on different parameters of cell membrane function were studied in 7 and 19 day chick embryonic hearts. The following changes were observed. 1.Transmembrane potential: A depolarization of the cell membrane and a decrease in the duration and in the overshoot of the action potential.2.Intracellular ion concentrations: A decrease in (K)i and an increase in (Na)i. Cellular Ca-content remained constant.3.K efflux: An increase in the rate coefficient, which was larger in stimulated preparations. These changes were more pronounced in 19 day than in 7 day hearts. The effects of hypoxia were increased by simultaneous substrate depletion and counteracted by an excess external glucose. We conclude that. 1.The 19 day hearts are more sensitive to oxygen lack than the 7 day hearts. This difference can be correlated with the observation that the younger hearts are able to consume more glycogen during hypoxia.2.The changes of the resting membrane potential and the overshoot of the action potential correlate with changes in respectively (K)i and (Na)i.3.An increase in the background K current may be an important factor in explaining the shortening of the action potential during hypoxia.

Where is the pilot? The changing shapes of governance in the European hospital sector.

Hospital governance refers to the complex of checks and balances that determine how decisions are made within the top structures of hospitals. This article explores the essentials of the concept by analysing the root notion of governance and comparing it with applications in other sectors. Recent developments that put pressure on the decision-making system within hospitals are outlined. Examples from the UK, France and the Netherlands are presented. Based on an evaluation of the current state of affairs, a research framework is developed, focusing on the determinants of governance configurations within the national healthcare systems and the wider legal and socio-economic context, as well as on the impact of governance configurations on the efficiency of the governing bodies and overall hospital performance. The article concludes with a preview of the European Hospital Governance Project, which follows the outlines of the described research framework. New techniques of data mining that are used in this project are explained by means of a real data example.