Management of obstetric anal sphincter injuries at the University Hospital of the West Indies

Up to 6% of women sustain severe perineal lacerations that involve the anal sphincters during vaginal delivery. When they occur obstetric anal sphincter injuries (OASI) may be accompanied by significant morbidity. Therefore, it is important to detect these injuries promptly and for experienced staff to perform sound repair. This report retrospectively assesses a series of seven women with OASI who were managed at a tertiary level hospital in Jamaica over a period of 28 months. Unfavourable details of management that may have adversely affected outcomes were sought from the various cases treated The incidence of OASI was low (0.2%). There were five third degree and two fourth degree lacerations. After these injuries were repaired, three patients (43%) experienced morbidity such as chronic pelvic pain (43%), anal incontinence (29%), dyspareunia (23%) and recto-vaginal fistulae (14%). In order to improve the outcomes at this institution, several aspects of current care can be improved. Operative repair of these injuries should be delayed until senior staff is available to supervise OASI repair. Both methods of sphincter repair are reasonable options but the use of rapidly absorbable sutures is not appropriate. Finally, prophylaxis against wound infections can be achieved by administering a single dose of intravenous second or third generation cephalosporin at the time of induction of anaesthesia.

A modified ATP benchmark for evaluating the cleaning of some hospital environmental surfaces

Hospital cleaning continues to attract patient, media and political attention. In the UK it is still primarily assessed via visual inspection, which can be misleading. Calls have therefore been made for a more objective approach to assessing surface cleanliness. To improve the management of hospital cleaning the use of adenosine triphosphate (ATP) in combination with microbiological analysis has been proposed, with a general ATP benchmark value of 500 relative light units (RLU) for one combination of test and equipment. In this study, the same test combination was used to assess cleaning effectiveness in a 1300-bed teaching hospital after routine and modified cleaning protocols. Based upon the ATP results a revised stricter pass/fail benchmark of 250 RLU is proposed for the range of surfaces used in this study. This was routinely achieved using modified best practice cleaning procedures which also gave reduced surface counts with, for example, aerobic colony counts reduced from >100 to <2.5 cfu/cm(2), and counts of Staphylococcus aureus reduced from up to 2.5 to <1 cfu/cm(2) (95% of the time). Benchmarking is linked to incremental quality improvements and both the original suggestion of 500 RLU and the revised figure of 250 RLU can be used by hospitals as part of this process. They can also be used in the assessment of novel cleaning methods, such as steam cleaning and microfibre cloths, which have potential use in the National Health Service.

Comparing no-touch and tympanic thermometer temperature recordings

Temperature is a vital sign which can be measured using various types of clinical thermometers. Pulmonary artery temperature is considered the 'gold standard', but this measurement is not usually clinically practical. There is currently no consensus for optimal alternative site or equipment. This research compares 178 simultaneous measurements from 5 clinical areas, using two types of thermometers: tympanic and no-touch temporal. No-touch thermometers were all set to oral equivalent. Tympanic thermometers were adjusted to either oral (n=105) or core (n=73) equivalent. Maximum acceptable difference was identified as 1oC. Two data sets (oral/core; oral/oral) were analysed using Bland-Altman method on Excel programmes, comparing all thermometers and separating oral and core-equivalent tympanics. The two thermometers were found not to be equivalent. As a simple comparison between two thermometers, this research cannot identify which thermometer is more accurate.

Intrapyloric injection of botulinum toxin a for the treatment of persistent gastroparesis following successful pancreas transplantation

Intrapyloric injection of botulinum toxin A (BoTx) successfully improved symptoms in idiopathic and diabetic gastroparesis (DGP) refractory to medical treatment. Therefore, we used it in three pancreas transplant patients done in our institution during the last 18 months. They had severe, persistent DGP despite successful pancreas transplantation. They received 100 units of BoTx during the first injection. The clinical effect became evident within 2 weeks after the treatment, and lasted for an average of 29 weeks (range 14-44 weeks). The patients' subjective evaluation showed improvement of their symptoms and quality of life following BoTx. Patients 2 and 3 had recurrent symptoms at 44 and 24 weeks, respectively, after the first injection; they required a second dose of 90 and 80 units, respectively. They are doing well at 3 months follow-up. Intrapyloric injection of BoTx is safe and efficient. It should be considered for treating residual DGP following successful pancreas transplantation.

A clinical audit of the quality of care of hypertension in general practice

Clinical audits monitor the use of particular interventions, or the care received by patients, against agreed standards. Any departures from "best practice" can then be examined, and causes can be determined and acted upon. The Ministry of Health (MOH), Jamaica, has recently published standards of care for hypertension. The medical records of a convenience sample of 125 hypertensive patients being managed by five current family medicine residents in their respective primary care practices were audited Initial results showed limited adherence to the MOH recommended hypertension management guidelines. The same practices were re-audited after an interval of six months, during which time the physicians were sensitized to the results of the preliminary audit. Marked improvements were noted in the second audit. Assessment for co-risk factors for hypertension-related diseases improved: nutritional advice (33% to 74%), smoking and alcohol intake history (40% to 65%) and history taking of physical activity (30% to 47%). Assessment for target organ damage also improved: fundoscopy done (11% to 54%), foot examination done (30% to 58%) and yearly electrolytes done (28% to 62%). There are clear gaps between current practice and standards that exist internationally and locally for management of hypertension. The MOH needs to disseminate and educate general practitioners about the standards of care guidelines.

Improving tracheostomy care for ward patients

The number of patients with a tracheostomy being cared for in the ward setting has increased recently as intensive care clinicians use this procedure to aid early weaning from mechanical ventilation. As a result, ward staff are providing the specialist care required by patients with a tracheostomy more frequently. This article describes how the outreach team and the critical care practice development nurse in one trust collaborated to identify, develop and implement strategies to ensure that patients with a tracheostomy in the ward setting would be cared for by an educated and supported team of nurses.