Ian Callanan

Use of a care bundle in the emergency department for acute exacerbations of chronic obstructive pulmonary disease: a feasibility study.

Aim To determine the efficacy and usefulness of a chronic obstructive pulmonary disease (COPD) care bundle designed for the initial management of acute exacerbations of COPD and to assess whether it improves quality of care and provides better outcomes. Introduction The level of care provided in the emergency department (ED) for COPD exacerbations varies greatly, and there is a need for a more systematic, consistent, evidence-based quality improvement approach to improve outcomes and costs. Methods A prospective before and after study was carried out in a university teaching hospital. Fifty consecutive patients were identified in the ED with COPD exacerbations and their management was reviewed. Following the education of ED staff and the implementation of a COPD care bundle, the outcome for 51 consecutive patients was analyzed. This COPD care bundle consisted of ten elements considered essential to the management of COPD exacerbations and was scored 0–10 according to the number of items on the checklist implemented correctly. Results Following implementation, the mean bundle score out of 10 improved from 4.6 to 7 (P<0.001). There was a significant decrease in the unnecessary use of intravenous corticosteroids from 60% to 32% (P=0.003) and also a marked improvement in the use of oxygen therapy, with appropriate treatment increasing from 76% to 96% (P=0.003). Prophylaxis for venous thromboembolism also improved from 54% to 73% (P=0.054). The 30-day readmission rate did not significantly improve. Conclusion The use of a bundle improves the delivery of care for COPD exacerbations in the ED. There is more appropriate use of therapeutic interventions, especially oxygen therapy and intravenous corticosteroids.

Herbert Screw Insertion in the Scaphotrapezial Joint A cause of degenerative change

The method of insertion of the Herbert screw for scaphoid fractures and its long-term presence in the scaphotrapezial joint may predispose to degeneration in that joint. We examined a group of patients with long-term follow-up to assess this risk and found it to be insignificant.

National early warning score (NEWS) – evaluation in surgery

PURPOSE The purpose of this paper is to evaluate staff opinion on the impact of the National Early Warning Score (NEWS) system on surgical wards. In 2012, the NEWS system was introduced to Irish hospitals on a phased basis as part of a national clinical programme in acute care. DESIGN/METHODOLOGY/APPROACH A modified established questionnaire was given to surgical nursing staff, surgical registrars, surgical senior house officers and surgical interns for completion six months following the introduction of the NEWS system into an Irish university hospital. FINDINGS Amongst the registrars, 89 per cent were unsure if the NEWS system would improve patient care. Less than half of staff felt consultants and surgical registrars supported the NEWS system. Staff felt the NEWS did not correlate well clinically with patients within the first 24 hours (Day zero) post-operatively. Furthermore, 78-85 per cent of nurses and registrars felt a rapid response team should be part of the escalation protocol. RESEARCH LIMITATIONS/IMPLICATIONS Senior medical staff were not convinced that the NEWS system may improve patient care. Appropriate audit proving a beneficial impact of the NEWS system on patient outcome may be essential in gaining support from senior doctors. Deficiencies with the system were also observed including the absence of a rapid response team as part of the escalation protocol and a lack of concordance of the NEWS in patients Day zero post-operatively. These issues should be addressed moving forward. ORIGINALITY/VALUE Appropriate audit of the impact of the NEWS system on patient outcome may be pertinent to obtain the support from senior doctors. Deficiencies with the system were also observed including the absence of a rapid response team as part of the escalation protocol and a lack of concordance of the NEWS in patients Day zero post-operatively. These issues should be addressed moving forward.

An audit of hospital based outpatient infusions and a pilot program of community-based monoclonal antibody infusions.

IntroductionInfliximab, a chimeric monoclonal antibody to tumour necrosis factor alpha, is administered as an intravenous infusion requiring a costly hospital day case or inpatient admission.Methods An audit of all current therapies given by intravenous infusions in an outpatient setting in St Vincent’s University Hospital (SVUH) was undertaken. Furthermore, in conjunction with TCP homecare, we established in a general practise health clinic, the first Irish community infusion centre for the administration of infliximab in August 2006.Results All outpatient departments indicated that they would favour a centralized hospital infusion unit. There were no adverse events and the mean global satisfaction improved in the community infliximab infusion pilot programme of seven patients.ConclusionThis study suggests efficiencies in providing centralized infusion facilities, while the community based infusion of infliximab is feasible and safe in this small cohort and identifies the community infusion unit as a viable and cost efficient alternative for administration of infliximab.

Hidden flexion injury of the cervical spine in ankylosing spondylitis

A 36.year-old man, who had been diagnosed as suffering from ankylosing spondylitis for the past ten years, was referred to our department for the evaluation and management of increasing flexion deformity of the cervical spine, 4 months after injuring his neck. He had fallen backwards and his occiput had hit the ground. Soon after the injury, he developed pain in the nape of the neck radiating to his right arm and paraesthesia in the C-6 dermatome. He attended another hospital where AP and lateral radiographs of the cervical spine were reported as normal apart from showing evidence of ankylosing spondylitis (Figure I). Over the subsequent 4 months the patient observed increasing pain and flexion deformity of his neck, and also revealed that supporting the chin with his hand partly relieved the pain and helped to correct his deformity. His neurological symptoms did not deteriorate. Repeated radiographs of the cervical spine showed forward subluxation of the C-5 vertebral body over C-6 and widening of the interspinous space in an ankylosed cervical spine (Figure 2). Review of the initial radiographs showed signs of the hidden flexion injury’. A magnetic resonance imaging (MRI) scan was performed. Interestingly the subluxation had reduced itself during the MRI examination. No extradural haematoma at the site of subluxation was identified (Figure 3). At operation, through an anterior approach, a ruptured anterior longitudinal ligament was found at the level of C-5/6. The disc structure was normal (the nucleus pulposus is not affected by ankylosing spondylitis)8. The disc was excised and a tricortical iliac bone graft was punched into the space. The C-5/6 vertebral bodies were fixed with a titanium locking screw plate (TLSP ~ Synthes)“. Paraesthesiae improved and radiographs taken 3 months post-operatively showed fusion of C-5/6 (Figure4).

Elbow fractures with carpal injuries

We report four cases with six episodes of concurrent carpal and elbow fractures or dislocations. Few such combinations of injuries have been reported in the literature. We discuss the mechanism and management of such injuries and conclude that elbow injuries should be suspected in severe carpal injuries. Surgical treatment may be required in their management.