Petra J. van Gurp

Sympathetic nervous system function in HIV-associated adipose redistribution syndrome.

It was recently suggested that HIV-associated adipose redistribution syndrome (HARS) results from an autonomic dysbalance. We investigated the local and global sympathetic nervous system function of patients with HIV-1 infection and HARS. Interstitial noradrenaline concentrations in skeletal muscle and subcutaneous adipose tissue were increased in the absence of changes in global sympathetic nerve activity, consistent with locally increased sympathetic activity. This could promote localized lipolysis in subcutaneous adipose tissue and contribute to the development of HARS.

Measurement of patient safety: a systematic review of the reliability and validity of adverse event detection with record review

Objectives Record review is the most used method to quantify patient safety. We systematically reviewed the reliability and validity of adverse event detection with record review. Design A systematic review of the literature. Methods We searched PubMed, EMBASE, CINAHL, PsycINFO and the Cochrane Library and from their inception through February 2015. We included all studies that aimed to describe the reliability and/or validity of record review. Two reviewers conducted data extraction. We pooled κ values (κ) and analysed the differences in subgroups according to number of reviewers, reviewer experience and training level, adjusted for the prevalence of adverse events. Results In 25 studies, the psychometric data of the Global Trigger Tool (GTT) and the Harvard Medical Practice Study (HMPS) were reported and 24 studies were included for statistical pooling. The inter-rater reliability of the GTT and HMPS showed a pooled κ of 0.65 and 0.55, respectively. The inter-rater agreement was statistically significantly higher when the group of reviewers within a study consisted of a maximum five reviewers. We found no studies reporting on the validity of the GTT and HMPS. Conclusions The reliability of record review is moderate to substantial and improved when a small group of reviewers carried out record review. The validity of the record review method has never been evaluated, while clinical data registries, autopsy or direct observations of patient care are potential reference methods that can be used to test concurrent validity.

Transport within the interstitial space, rather than membrane permeability, determines norepinephrine recovery in microdialysis.

Microdialysis is a sampling method that permits measurement of hormones, drugs, and other lower molecular weight compounds present in interstitial fluid. We developed a straightforward mathematical model that predicts a linear relationship between the reciprocal dialysate concentration of the analyte from the interstitium and perfusion rate, permitting estimation of the interstitial concentration by extrapolation to zero perfusion rate. Conversely, linearity between the reciprocal dialysate concentration of internal standard added to the perfusion medium (retrodialysis), and the reciprocal perfusion rate, is predicted. In nine healthy volunteers, interstitial norepinephrine (NE) was estimated by NE measurements in microdialysates obtained from skeletal muscle and adipose subcutaneous tissue, using sodium salicylate (Sal) in the perfusion buffer as internal standard, at perfusion rates of 2 and 5 μl/min. Comparison with microdialysis in vitro by immersing the probe in a large volume of buffer containing NE showed that the in vivo (retro)recovery of NE and Sal is almost exclusively determined by transport of NE through the interstitial space toward and Sal from the membrane and that membrane permeability itself plays a negligible role. This was supported by the observation that applying lower body negative pressure, a measure that is unlikely to affect membrane permeability, resulted in a significant (p < 0.05) decrease of Sal retrorecovery from muscle interstitium. This validated new model significantly adds insight into the factors determining recovery of substances from the interstitium in microdialysis and provides a simpler alternative to previous approaches for estimation of interstitial concentrations.

Observable phenomena that reveal medical students' clinical reasoning ability during expert assessment of their history taking: a qualitative study

BackgroundDuring their clerkships, medical students are meant to expand their clinical reasoning skills during their patient encounters. Observation of these encounters could reveal important information on the students’ clinical reasoning abilities, especially during history taking.MethodsA grounded theory approach was used to analyze what expert physicians apply as indicators in their assessment of medical students’ diagnostic reasoning abilities during history taking. Twelve randomly selected clinical encounter recordings of students at the end of the internal medicine clerkships were observed by six expert assessors, who were prompted to formulate their assessment criteria in a think-aloud procedure. These formulations were then analyzed to identify the common denominators and leading principles.ResultsThe main indicators of clinical reasoning ability were abstracted from students’ observable acts during history taking in the encounter. These were: taking control, recognizing and responding to relevant information, specifying symptoms, asking specific questions that point to pathophysiological thinking, placing questions in a logical order, checking agreement with patients, summarizing and body language. In addition, patients’ acts and the course, result and efficiency of the conversation were identified as indicators of clinical reasoning, whereas context, using self as a reference, and emotion/feelings were identified by the clinicians as variables in their assessment of clinical reasoning.ConclusionsIn observing and assessing clinical reasoning during history taking by medical students, general and specific phenomena to be used as indicators for this process could be identified. These phenomena can be traced back to theories on the development and the process of clinical reasoning.

Major gaps between recommended perioperative diabetes care and current practice

Surgery for patients with diabetes is associated with longer hospital stay, more use of healthcare resources and increased perioperative morbidity and mortality compared to patients without diabetes [1,2]. This may – in part – be explained by suboptimal perioperative diabetes care. Several large professional organizations have developed recommendations for optimal perioperative diabetes care, but it is unknown whether this has resulted in optimal care delivery [3,4]. Perioperative diabetes care is a complex and multidisciplinary process. The hospital care pathway ranges from the preoperative evaluation up to hospital discharge, and is characterized by multiple care transitions and multiprofessional involvement. To achieve optimal perioperative diabetes care, all professionals involved should take the specific needs of the personwith diabetes into account at all stages of the hospital care pathway from preoperative evaluation to hospital discharge [3]. In a previous study, we developed and tested quality indicators for optimal perioperative diabetes care throughout the hospital care pathway [5]. The quality indicators are based on international guidelines and literature and a systematic RAND Modified Delphi procedure [6]. The indicator set consists of 21 quality indicators, including 3 outcome, 9 process, and 9 structure indicators. Here, we report the results of an assessment of the quality of perioperative diabetes care in the Netherlands, using these quality indicators. We included 389 participants with diabetes who underwent abdominal (32%), cardiac (29%), or large joint orthopedic surgery (39%) in six Dutch hospitals. There were two university hospitals, two medium-size teaching hospitals, and two large non-university teaching hospitals. About half of the participants (57%) were treated with oral hypoglycemic agents only prior to hospital admission, 21% used a combination of oral hypoglycemic agents and insulin, 8% used insulin only, and 4% took dietary measures only. The data relevant to the outcome and process indicators were collected from the patient records. The organizational structure of perioperative diabetes care was assessed with a questionnaire that was completed by a diabetes specialist in each participating hospital. We computed overall indicator scores (in percentages) by dividing the number of participants who received the recommended care as described by the indicator (numerator) by the number of participants to whom the recommended care applied (denominator). To gain insight into the variation in indicator scores between the hospitals, we calculated individual hospital scores and themedian of these scores.We studied the relationship between the indicator scores and participant characteristics (age, gender, diabetes treatment, and type of surgery). Participant characteristics with a significant influence on the indicator scores were

Process evaluation of the effects of patient safety auditing in hospital care (part 2)

Abstract Objective To identify factors that explain the observed effects of internal auditing on improving patient safety. Design setting and participants A process evaluation study within eight departments of a university medical centre in the Netherlands. Intervention(s) Internal auditing and feedback for improving patient safety in hospital care. Main outcome measure(s) Experiences with patient safety auditing, percentage implemented improvement actions tailored to the audit results and perceived factors that hindered or facilitated the implementation of improvement actions. Results The respondents had positive audit experiences, with the exception of the amount of preparatory work by departments. Fifteen months after the audit visit, 21% of the intended improvement actions based on the audit results were completely implemented. Factors that hindered implementation were short implementation time: 9 months (range 5–11 months) instead of the 15 months’ planned implementation time; time-consuming and labour-intensive implementation of improvement actions; and limited organizational support for quality improvement (e.g. insufficient staff capacity and time, no available quality improvement data and information and communication technological (ICT) support). Conclusions A well-constructed analysis and feedback of patient safety problems is insufficient to reduce the occurrence of poor patient safety outcomes. Without focus and support in the implementation of audit-based improvement actions, quality improvement by patient safety auditing will remain limited.

Effects of patient safety auditing in hospital care: results of a mixed-method evaluation (part 1)

Abstract Objective To evaluate the effectiveness of internal auditing in hospital care focussed on improving patient safety. Design, Setting and Participants A before-and-after mixed-method evaluation study was carried out in eight departments of a university medical center in the Netherlands. Intervention(s) Internal auditing and feedback focussed on improving patient safety. Main Outcome Measure(s) The effect of internal auditing was assessed 15 months after the audit, using linear mixed models, on the patient, professional, team and departmental levels. The measurement methods were patient record review on adverse events (AEs), surveys regarding patient experiences, safety culture and team climate, analysis of administrative hospital data (standardized mortality rate, SMR) and safety walk rounds (SWRs) to observe frontline care processes on safety. Results The AE rate decreased from 36.1% to 31.3% and the preventable AE rate from 5.5% to 3.6%; however, the differences before and after auditing were not statistically significant. The patient-reported experience measures regarding patient safety improved slightly over time (P < 0.001). The SMR, patient safety culture and team climate remained unchanged after the internal audit. The SWRs showed that medication safety and information security were improved (P < 0.05). Conclusions Internal auditing was associated with improved patient experiences and observed safety on wards. No effects were found on adverse outcomes, safety culture and team climate 15 months after the internal audit.

Reactive Rather than Proactive Diabetes Management in the Perioperative Period

As perioperative hyperglycemia is associated with poor postoperative patient outcomes, clinical guidelines provide recommendations for optimal perioperative glucose control. It is unclear to what extent recommended glucose levels are met in daily practice, and little is known about factors that influence these levels. We describe blood glucose levels throughout the hospital care pathway in 375 non-critically ill patients with diabetes who underwent major surgery (abdominal, cardiac, or orthopedic) in 6 hospitals, examine determinants of these levels including adherence to 9 quality indicators for optimal perioperative diabetes care, and perform qualitative interviews to identify barriers for optimal care. Virtually all patients (95%) experienced at least one hyperglycemic value (>10 mmol/l); 9% had at least one value <4 mmol/l. Mean glucose increased from preoperative to postoperative day (POD) 1 (+2.3 mmol/l, 5-95% CI 1.9-2.7), and then gradually decreased on POD 2-14 (+1.8 mmol/l, 5-95% CI 1.4-2.2). Insulin-treated patients (with or without oral agents) had higher glucose levels (+1.7 mmol/l, 5-95% CI 0.5-3.0, and +1.2 mmol/l, -0.1 to -2.5) than patients using oral agents only. Indicator adherence tended to be associated with higher glucose levels. Barriers for optimal care included a lack of formalized agreements on target glucose levels, absence of directly obvious disadvantages of hyperglycemia, and concern about inducing hypoglycemia. Hyperglycemia is common after major surgery, in particular on POD1 and in insulin-treated patients. Our results suggest that perioperative diabetes care is reactive rather than proactive, and that current emphasis of professionals is on treating instead of preventing postoperative hyperglycemia.