Confined space manure storage and facilities safety assessment

A mail survey of 1,200 farms across 16 states was conducted to identify the number, type, and size of manure storages per farm, as well as safety-related behaviors or actions related to entry into confined-space manure storage and handling facilities. Respondents provided data on 297 storage units and facilities, with approximately 75% reporting up to three storages per farm operation. Dimensions were provided for 254 manure pits: nearly 66% were less than or equal to 100 feet long, 75% were less than or equal to 40 feet wide, and 75% were less than or equal to 10 feet deep. Almost 14% of the reported storages were over 300 feet long, seven were wider than 100 feet, and 17 were more than 20 feet deep. Survey results suggest that most farm operations with confined-space manure storages do not follow best safety practices regarding their manure storages, including using gas detection equipment before entering a manure pit, using rescue lines when entering storages, or developing a written confined-space safety policy or plan. Survey results also suggest that few farmers post warning signs around their storages, post recommended ventilation times before entry, or conduct training for workers who enter confined-space manure storages. This article provides a benchmark against which the effectiveness of educational programs and design tools for confined-space manure pit ventilation systems and other confined-space manure pit safety interventions can be measured.

Red blood cell transfusion practices in two surgical intensive care units: a mixed methods assessment of barriers to evidence-based practice

BACKGROUND

Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence.

STUDY DESIGN AND METHODS

A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland.

RESULTS

Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers.

CONCLUSIONS

Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.

The implications of the declining energy return on investment of oil production

Declining production from conventional oil resources has initiated a global transition to unconventional oil, such as tar sands. Unconventional oil is generally harder to extract than conventional oil and is expected to have a (much) lower energy return on (energy) investment (EROI). Recently, there has been a surge in publications estimating the EROI of a number of different sources of oil, and others relating EROI to long-term economic growth, profitability and oil prices. The following points seem clear from a review of the literature: (i) the EROI of global oil production is roughly 17 and declining, while that for the USA is 11 and declining; (ii) the EROI of ultra-deep-water oil and oil sands is below 10; (iii) the relation between the EROI and the price of oil is inverse and exponential; (iv) as EROI declines below 10, a point is reached when the relation between EROI and price becomes highly nonlinear; and (v) the minimum oil price needed to increase the oil supply in the near term is at levels consistent with levels that have induced past economic recessions. From these points, I conclude that, as the EROI of the average barrel of oil declines, long-term economic growth will become harder to achieve and come at an increasingly higher financial, energetic and environmental cost.

Comparison of uptake and predictors of adherence in primary and secondary prevention of cardiovascular disease in a community-based cardiovascular prevention programme (MyAction Westminster)

BACKGROUND

Despite the benefits of cardiac rehabilitation, uptake and adherence remain suboptimal. With the advent of NHS Health Checks, primary prevention programmes have also been advocated, but little is known about uptake and adherence rates. This study examined rates and predictors of adherence amongst patients with cardiovascular disease (CVD) and those at high multifactorial risk (HRI) attending an innovative programme integrating primary and secondary prevention.

METHODS

Comparison of rates of uptake and adherence and also predictors of adherence between 401 CVD patients and 483 HRI. The outcome was the number of sessions attended and predictor variables included clinical and psychosocial variables. Differences between groups were examined using t-tests and non-parametric tests. Multivariable regression analyses examined predictors of adherence.

RESULTS

Uptake to the assessment (CVD: 97%, HRI: 88%) and the programme (CVD: 78%, HRI: 74%) were high for both groups. An average of 8/12 was attended in both groups. Beliefs about treatment predicted adherence for both groups (P < 0.01). The alcohol causal belief also predicted poorer adherence amongst CVD patients (P < 0.02). Older age also predicted better adherence amongst HRI (P < 0.001).

CONCLUSIONS

Rates of uptake and adherence were high for both HRI and CVD patients. Further research is needed to examine whether interventions targeting predictor variables further improve adherence.

Changes in transfusion practice over time in the PICU

OBJECTIVES

Recent randomized clinical trials have shown the efficacy of a restrictive transfusion strategy in critically ill children. The impact of these trials on pediatric transfusion practice is unknown. Additionally, long-term trends in pediatric transfusion practice in the ICU have not been described. We assessed transfusion practice over time, including the effect of clinical trial publication.

DESIGN

Single-center, retrospective observational study.

SETTING

A 10-bed PICU in an urban academic medical center.

PATIENTS

Critically ill, nonbleeding children between the ages of 3 days and 14 years old, admitted to the University of Maryland Medical Center PICU between January 1, 1998, and December 31, 2009, excluding those with congenital heart disease, hemolytic anemia, and hemoglobinopathies.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During the time period studied, 5,327 patients met inclusion criteria. Of these, 335 received at least one RBC transfusion while in the PICU. The overall proportion transfused declined from 10.5% in 1998 to 6.8% in 2009 (p = 0.007). Adjusted for acuity, the likelihood of transfusion decreased by calendar year of admission. In transfused patients, the pretransfusion hemoglobin level declined, from 10.5 g/dL to 9.3 g/dL, though these changes failed to meet statistical significance (p = 0.09). Neonatal age, respiratory failure, shock, multiple organ dysfunction syndrome, and acidosis were associated with an increased likelihood of transfusion in both univariate and multivariable models.

CONCLUSIONS

The overall proportion of patients transfused between 1998 and 2009 decreased significantly. The magnitude of the decrease varied over time, and no additional change in transfusion practice occurred after the publication of a major pediatric clinical trial in 2007. Greater illness acuity and younger patient age were associated with an increased likelihood of transfusion.

Delivery outcomes for nulliparous women at the extremes of maternal age - a cohort study

OBJECTIVE

To examine the associations between extremes of maternal age (≤17 years or ≥40 years) and delivery outcomes.

DESIGN

Retrospective cohort study.

SETTING

Urban maternity hospital in Ireland.

POPULATION

A total of 36 916 nulliparous women with singleton pregnancies who delivered between 2000 and 2011.

METHODS

The study population was subdivided into five maternal age groups based on age at first booking visit: ≤17 years, 18-19 years, 20-34 years, 35-39 years and women aged ≥40 years. Logistic regression analyses were performed to examine the associations between extremes of maternal age and delivery outcomes, adjusting for potential confounding factors.

MAIN OUTCOME MEASURES

Preterm birth, admission to the neonatal unit, congenital anomaly, caesarean section.

RESULTS

Compared with maternal age 20-34 years, age ≤17 years was a risk factor for preterm birth (adjusted odds ratio [adjOR] 1.83, 95% confidence interval [95% CI] 1.33-2.52). Babies born to mothers ≥40 years were more likely to require admission to the neonatal unit (adjOR 1.35, 95% CI 1.06-1.72) and to have a congenital anomaly (adjOR 1.71, 95% CI 1.07-2.76). The overall caesarean section rate in nulliparous women was 23.9% with marked differences at the extremes of maternal age; 10.7% at age ≤17 years (adjOR 0.46, 95% CI 0.34-0.62) and 54.4% at age ≥40 years (adjOR 3.24, 95% CI 2.67-3.94).

CONCLUSIONS

Extremes of maternal age need to be recognised as risk factors for adverse delivery outcomes. Low caesarean section rates in younger women suggest that a reduction in overall caesarean section rates may be possible.

Energy return on investment, peak oil, and the end of economic growth

Economic growth over the past 40 years has used increasing quantities of fossil energy, and most importantly oil. Yet, our ability to increase the global supply of conventional crude oil much beyond current levels is doubtful, which may pose a problem for continued economic growth. Our research indicates that, due to the depletion of conventional, and hence cheap, crude oil supplies (i.e., peak oil), increasing the supply of oil in the future would require exploiting lower quality resources (i.e., expensive), and thus could occur only at high prices. This situation creates a system of feedbacks that can be aptly described as an economic growth paradox: increasing the oil supply to support economic growth will require high oil prices that will undermine that economic growth. From this we conclude that the economic growth of the past 40 years is unlikely to continue in the long term unless there is some remarkable change in how we manage our economy.

Transfusion practice in the intensive care unit: a 10-year analysis

BACKGROUND

Clinical guidelines recommend a restrictive transfusion strategy in nonhemorrhaging critically ill patients.

STUDY DESIGN AND METHODS

We conducted a retrospective observational study of 3533 single-admission patients, without evidence of acute coronary syndromes, hemorrhage, or hemoglobinopathy admitted to the medical intensive care unit (MICU) of a large, academic medical center.

RESULTS

MICU admission hemoglobin (Hb) level did not change significantly over the study period. The proportion of transfused patients decreased from 31.0% in 1997 to 1998 to 18.0% in 2006 to 2007 (p<0.001). Among patients receiving transfusion, the mean pretransfusion Hb level decreased over time from 7.9±1.3 to 7.3±1.3g/dL (p<0.001). These changes in practice were not accounted for by differences in patient characteristics. The mean nadir Hb level in nontransfused patients decreased from 11.2±2.2g/dL in 1997 to 1999 to 10.4±2.3g/dL in 2006 to 2007 (p<0.001). The mean number of units per patient transfused decreased during this time from 4.3±4.7 to 3.0±3.8 units (p<0.001). The proportion of transfused patients who were transfused at a Hb level of less than 7.0g/dL increased by an estimated absolute increment of 3.2% (95% CI, 2.1%-4.3%) per interval (p<0.001), and the proportion of single-unit transfusions during the first transfusion episode increased by 1.4% per interval (95% CI, 0.2 to 2.6%; p=0.03) from 40.2% in 1997 to 1998 to 53.1% in 2006 to 2007.

CONCLUSIONS

Between 1997 and 2007, important and sustained changes have occurred in our MICU physician transfusion practices, with overall reductions in the proportion of patients transfused, mean pretransfusion Hb level, and nadir Hb level in patients who were not transfused.

Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations

Central line-associated bloodstream infections (CLABSIs) acquired in health care institutions are common and costly. A novel monitoring and prevention program dramatically reduced CLABSIs across one state. The extent to which other states have adopted similar efforts is unknown. State hospital associations were surveyed regarding their efforts to address these infections. All 50 responding associations endorsed the importance of improving patient safety, health care quality, or health care-associated infections. Although 42 (84%) cited CLABSIs as a priority, only 11 (22%) provided statewide CLABSI rates. CLABSI programs were active in 6 (12%) states, and an additional 7 (14%) states were planning programs. Barriers identified included a lack of coordinated priorities, limited infrastructure, and inadequate resources. Although associations support efforts to improve health care quality, including CLABSI prevention, most lack coordinated statewide monitoring and prevention programs. A national collaborative to address CLABSIs may reduce these infections while building capacity to improve other aspects of health care quality.

ICU staffing and patient outcomes: more work remains

Many studies have demonstrated that closed intensive care units (ICUs), staffed by trained intensivists, are associated with improved patient outcomes. However, the mechanisms by which ICU organizational factors, such as physician staffing, influence patient outcomes are unclear. One potential mechanism is the increased utilization of evidence-based practices in closed ICUs. Cooke and colleagues investigated this hypothesis in a cohort of 759 acute lung injury patients in 23 ICUs in King County, Washington, USA. Although closed ICUs were independently associated with a modestly lower mean tidal volume, this finding did not explain the mortality benefit associated with a closed ICU model in this patient cohort. Future studies should evaluate other potential mechanisms by which closed ICUs improve patient outcomes. An improved understanding of these mechanisms may yield new targets for improving the quality of medical care for all ICU patients.

A practical tool to identify and eliminate barriers to compliance with evidence-based guidelines

A practical tool provides an interdisciplinary approach to identify barriers to guideline compliance and implement actions to eliminate or mitigate the effect of the barriers.

A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study

OBJECTIVE

To compare the maternal and neonatal outcomes of operative vaginal delivery in relation to the use of episiotomy.

DESIGN

Pilot randomised controlled trial (RCT).

SETTING

Two urban maternity units in Scotland and England.

SAMPLE

Nulliparous women anticipating a singleton cephalic vaginal delivery were recruited in the antenatal period.

METHODS

If an operative vaginal delivery was required in the second stage of labour, women were randomised to either routine (in all cases) or restrictive (only if tearing apparent) use of episiotomy.

MAIN OUTCOME MEASURES

The primary outcome was anal sphincter tearing (third or fourth degree). Secondary outcomes included postpartum haemorrhage (PPH), neonatal trauma and pelvic floor symptoms up until 10 days postpartum.

RESULTS

In a group of 317 women requiring operative vaginal delivery, 200 were randomised: 99 to routine use of episiotomy and 101 to restrictive use. There were small differences in the rates of anal sphincter tears (8.1% routine versus 10.9% restrictive, OR 0.72, 95% CI 0.28-1.87) and primary PPH (36.4% routine versus 26.7% restrictive, OR 1.57, 95% CI 0.86-2.86). Neonatal trauma was similar between the two groups (45.5% routine versus 43.6% restrictive, OR 1.08, 95% CI 0.62-1.89), as was prolonged catheterisation, urinary incontinence, faecal incontinence, perineal infection and prolonged hospital admission.

CONCLUSIONS

This pilot study does not provide conclusive evidence that a policy of routine episiotomy is better or worse than a restrictive policy. A definitive RCT is feasible but will require a large sample size to inform clinical practice.