Proceedings of the 12th International Conference on Rapid Response Systems and Medical Emergency Teams

Rapid Response Teams (RRTs) have been introduced into hospitals worldwide in an effort to improve the outcomes of deteriorating hospitalised patients. Recently, there has been increased awareness of the need to develop systems other than RRTs for deteriorating patients. In May 2016, the 12th International Conference on Rapid Response Systems and Medical Emergency Teams was held in Melbourne. This represented a collaboration between the newly constituted International Society for Rapid Response Systems (iSRRS) and the Australian and New Zealand Intensive Care Society. The conference program included broad ranging presentations related to general clinical deterioration in the acute care setting, as well as deterioration in the emergency department, during pregnancy, in the paediatric setting, and deterioration in mental health status. This article briefly summarises the key features of the conference, links to presentations, and the 18 abstracts of the accepted free papers.

A systems science perspective on the capacity for change in public hospitals

Many types of organisation are difficult to change, mainly due to structural, cultural and contextual barriers. Change in public hospitals is arguably even more problematic than in other types of hospitals, due to features such as structural dysfunctionalities and bureaucracy stemming from being publicly-run institutions. The main goals of this commentary are to bring into focus and highlight the "3 + 3 Decision Framework" proposed by Edwards and Saltman. This aims to help guide policymakers and managers implementing productive change in public hospitals. However, while change from the top is popular, there are powerful front-line clinicians, especially doctors, who can act to counterbalance top-down efforts. Front-line clinicians have cultural characteristics and power that allows them to influence or reject managerial decisions. Clinicians in various lower-level roles can also influence other clinicians to resist or ignore management requirements. The context is further complicated by multi-stakeholder agendas, differing goals, and accumulated inertia. The special status of clinicians, along with other system features of public hospitals, should be factored into efforts to realise major system improvements and progressive change.

Effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: a systematic review and meta-analysis

BACKGROUND

Vital signs monitoring is an old hospital practice for patient safety but evaluation of its effectiveness is not widespread. We aimed to identify strategies to improve intermittent or continuous vital signs monitoring in general wards; and their effectiveness in preventing adverse events on general hospital wards.

METHODS

Publications searched between 1980 and June 2014 in five databases. Main outcome measures were in-hospital death, cardiac arrest, intensive care unit (ICU) transfers, length of stay, identification of physiological deterioration and activation of rapid response systems.

RESULTS

Twenty-two studies assessing the effect of continuous (9) or intermittent monitoring (13) and reporting outcomes on 203,407 patients in-hospital wards across 13 countries were included in this review. Both monitoring practices led to early identification of patient deterioration, increased rapid response activations and improvements in timeliness or completeness of vital signs documentation. Innovative intermittent monitoring approaches are associated with modest reduction in in-hospital mortality over intermittent vital signs monitoring in 'usual care'. However, there was no evidence of significant reduction in ICU transfers or other adverse events with either intermittent or continuous monitoring.

CONCLUSIONS

This review of heterogeneous monitoring approaches found no conclusive confirmation of improvements in prevention of cardiac arrest, reduction in length of hospital stay, or prevention of other neurological or cardiovascular adverse events. The evidence found to date is insufficient to recommend continuous vital signs monitoring in general wards as routine practice. Future evaluations of effectiveness need to be undertaken with more rigorous methods and homogeneous outcome measurements.

Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem

PURPOSE

To investigate the extent of objective 'non-beneficial treatments (NBTs)' (too much) anytime in the last 6 months of life in routine hospital care.

DATA SOURCES

English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-April 2015).

STUDY SELECTION

All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL).

DATA EXTRACTION

A 13-item quality score estimated independently by two authors.

RESULTS OF DATA SYNTHESIS

Evidence from 38 studies indicates that on average 33-38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11-90%). Mean death in intensive care unit (ICU) was 42% (range 11-90%); and mean death rate in a hospital ward was 44.5% (range 29-60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7-77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11-75% (mean 38%). Non-beneficial tests were performed on 33-50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0-33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24-41%).

CONCLUSION

This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.

Risk factors for low birth weight in a socio-economically disadvantaged population: parity, marital status, ethnicity and cigarette smoking

Low birth weight (LBW) is a public health problem, because it is associated with increased risk of morbidity and mortality. The principal aim of this study was to assess risk factors for LBW in a large multi-ethnic and socio-economically disadvantaged population. Data from 3242 mothers, who attended the Well Baby Clinic (Southwestern Sydney, Australia) for the first time, were analysed in relation to their demographic characteristics and socio-economic indices. The overall birthweight was 3377 +/- 577 g (mean +/- SD). In multiple linear regression analysis, smoking during pregnancy, marital status, parity, and country of birth were independently associated with birth weight. According to this analysis, lower birth weight was associated with mothers who had smoked during pregnancy (by 215.2 +/- 18.6 g), who were single (46.9 +/- 21 g), and of Asian background (108.5 +/- 38.2 g). However, higher parity was associated with significantly higher birth weight. The presence of each factor was coded as 1 and the absence, 0. A 'risk score' was then derived by summing up the individual scores. When birth weight was classified as 'low birth weight' (defined as those with birth weight being less than 2500 g) or normal birth weight, the overall prevalence of LBW was 1.9%. Each unit increase in the risk score was associated with a 1.9-fold (95% confidence interval: 1.5-2.6) increase in the risk of LBW. These data suggest that apart from marital status, ethnicity and parity, maternal smoking is the single most important preventable risk factors for LBW.

Vital signs monitoring and nurse-patient interaction: A qualitative observational study of hospital practice

BACKGROUND

High profile safety failures have demonstrated that recognising early warning signs of clinical and physiological deterioration can prevent or reduce harm resulting from serious adverse events. Early warning scoring systems are now routinely used in many places to detect and escalate deteriorating patients. Timely and accurate vital signs monitoring are critical for ensuring patient safety through providing data for early warning scoring systems, but little is known about current monitoring practices.

OBJECTIVE

To establish a profile of nurses' vital signs monitoring practices, related dialogue, and adherence to health service protocol in New South Wales, Australia.

METHODS

Direct observations of nurses' working practices were conducted in two wards. The observations focused on times of the day when vital signs were generally measured. Patient interactions were recorded if occurring any time during the observation periods. Participants (n=42) included nursing staff on one chronic disease medical and one acute surgical ward in a large urban teaching hospital in New South Wales.

RESULTS

We observed 441 patient interactions. Measurement of vital signs occurred in 52% of interactions. The minimum five vital signs measures required by New South Wales Health policy were taken in only 6-21% of instances of vital signs monitoring. Vital signs were documented immediately on 93% of vitals-taking occasions and documented according to the policy in the patient's chart on 89% of these occasions. Nurse-patient interactions were initiated for the purpose of taking vital signs in 49% of interactions, with nurse-patient discourse observed during 88% of all interactions. Nurse-patient dialogue led to additional care being provided to patients in 12% of interactions.

CONCLUSION

The selection of appropriate vital signs measured and responses to these appears to rely on nurses' clinical judgement or time availability rather than on policy-mandated frequency. The prevalence of incomplete sets of vital signs may limit identification of deteriorating patients. The findings from this study present an important baseline profile against which to evaluate the impact of introducing continuous monitoring approaches on current hospital practice.

Long-Range Modulation of PAG1 Expression by 8q21 Allergy Risk Variants

The gene(s) whose expression is regulated by allergy risk variants is unknown for many loci identified through genome-wide association studies. Addressing this knowledge gap might point to new therapeutic targets for allergic disease. The aim of this study was to identify the target gene(s) and the functional variant(s) underlying the association between rs7009110 on chromosome 8q21 and allergies. Eight genes are located within 1 Mb of rs7009110. Multivariate association analysis of publicly available exon expression levels from lymphoblastoid cell lines (LCLs) identified a significant association between rs7009110 and the expression of a single gene, PAG1 (p = 0.0017), 732 kb away. Analysis of histone modifications and DNase I hypersensitive sites in LCLs identified four putative regulatory elements (PREs) in the region. Chromosome conformation capture confirmed that two PREs interacted with the PAG1 promoter, one in allele-specific fashion. To determine whether these PREs were functional, LCLs were transfected with PAG1 promoter-driven luciferase reporter constructs. PRE3 acted as a transcriptional enhancer for PAG1 exclusively when it carried the rs2370615:C allergy predisposing allele, a variant in complete linkage disequilibrium with rs7009110. As such, rs2370615, which overlaps RelA transcription factor (TF) binding in LCLs and was found to disrupt Foxo3a binding to PRE3, represents the putative functional variant in this locus. Our studies suggest that the risk-associated allele of rs2370615 predisposes to allergic disease by increasing PAG1 expression, which might promote B cell activation and have a pro-inflammatory effect. Inhibition of PAG1 expression or function might have therapeutic potential for allergic diseases.

Findings of the first ANZICS conference on the role of intensive care in Rapid Response Teams

Rapid Response Teams (RRTs) are specialised teams introduced into hospitals to improve the outcomes of deteriorating ward patients. Although Rapid Response Systems (RRSs) were developed by the intensive care unit (ICU) community, there is variability in their delivery, and consultant involvement, supervision and leadership appears to be relatively infrequent. In July 2014, the Australian and New Zealand Intensive Care Society (ANZICS) convened the first conference on the role of intensive care medicine in RRTs in Australia and New Zealand. The conference explored RRSs in the broader role of patient safety, resourcing and staffing of RRTs, effect on ICU workload, different RRT models, the outcomes of RRT patients and original research projects in the area of RRSs. Issues around education and training of both ICU registrars and nurses were examined, and the role of team training explored. Measures to assess the effectiveness of the RRS and RRT at the level of health system and hospital, team performance and team effectiveness were discussed, and the need to develop a bi-national ANZICS RRT patient database was presented. Strategies to prevent patient deterioration in the 'pre-RRT' period were discussed, including education of ward nurses and doctors, as well as an overarching governance structure. The role of the ICU in deteriorating ward patients was debated and an integrated model of acute care presented. This article summarises the findings of the conference and presents recommendations on the role of intensive care medicine in RRTs in Australia and New Zealand.

Reliability of intra-abdominal pressure measurements using the modified Kron technique

OBJECTIVES

Assessment of intra-abdominal pressure (IAP) and the likelihood of abdominal compartment syndrome using valid and reliable measures is an important tool in the assessment of critically ill patients. The current method of relying on a single IAP per measurement period to determine patient clinical status raises the question: is a single intermittent IAP measurement an accurate indicator of clinical status or should more than one measurement be taken per measurement period?

METHODS

This study sought to assess the reliability of IAP measurements. Measurements were taken using the modified Kron technique. A total of two transvesical intra-abdominal pressure measurements were undertaken per patient using a standardized protocol. Recordings were taken at intervals of 5 minutes.

RESULTS

The majority of participants (58%) were surgical patients. Thirty-two were males and the mean age was 58 years (SD: 16·7 years). The concordance correlation coefficient between the two measurements was 0·95. Both the scatter and Bland-Altman plots demonstrate that the comparisons of two measurements are highly reproducible.

CONCLUSION

The findings of this study suggest that conducting two IAP measurements on single patient produce comparable results; therefore, there appears to be no advantage in doing two IAP measurements on a single patient. The measurement of an IAP requires the implementation of a standardized protocol and competent and credentialed assessors trained in the procedure.

Functional variants at the 11q13 risk locus for breast cancer regulate cyclin D1 expression through long-range enhancers

Analysis of 4,405 variants in 89,050 European subjects from 41 case-control studies identified three independent association signals for estrogen-receptor-positive tumors at 11q13. The strongest signal maps to a transcriptional enhancer element in which the G allele of the best candidate causative variant rs554219 increases risk of breast cancer, reduces both binding of ELK4 transcription factor and luciferase activity in reporter assays, and may be associated with low cyclin D1 protein levels in tumors. Another candidate variant, rs78540526, lies in the same enhancer element. Risk association signal 2, rs75915166, creates a GATA3 binding site within a silencer element. Chromatin conformation studies demonstrate that these enhancer and silencer elements interact with each other and with their likely target gene, CCND1.

The effect of herbs and their associated essential oils on performance, dietary digestibility and gut microflora in chickens from 7 to 28 days of age

1. The effect of the dietary inclusion of 5 culinary herbs or their essential oils on the growth, digestibility and intestinal microflora status in female broiler chicks was assessed. From 7 to 28 d of age, either a basal control diet without supplement was given or one of 10 others, consisting of the basal diet with either 10 g/kg herb (thyme, oregano, marjoram, rosemary or yarrow) or 1 g/kg of essential oil. 2. Body mass (BM) and feed consumption (AFC) were measured on a weekly basis and used to calculate chick performance. Total viable counts of lactic acid bacteria, coliforms, anaerobes and Clostridium perfringens were determined at 25 d. Apparent nutrient digestibilities were calculated from the measured values for gross energy, nitrogen (N), dry matter (DM) and organic matter, and sialic acid concentration was also measured. 3. Generally, dietary thyme oil or yarrow herb inclusion had the most positive effects on chick performance, while oregano herb and yarrow oil were the poorest supplements. Only thyme and yarrow in these diets had a different effect when used as a herb or oil on weight gain and BM. 4. Dietary treatment had no effect on the intestinal microflora populations, apparent metabolisable energy (AME) or the calculated coefficients of digestibility. Sialic acid concentration was greatest in the birds given dietary thyme oil, compared with all other treatments except those birds receiving marjoram oil, rosemary herb and the controls. However, less sialic acid was excreted in those birds given diets with oregano or rosemary oils, or oregano herb, than in the controls. 5. Plant extracts in diets may therefore affect chick performance, gut health and endogenous secretions, although the chemical composition of the extract appears to be important in obtaining the optimal effects.

Epidemiology of porcine non-specific colitis on Scottish farms

The objective of this study was to investigate epidemiological risk factors for porcine non-specific colitis (NSC). Forty-seven Scottish pig farms, with and without a clinical history of diarrhoea during the growing period (15-40 kg), were selected. The study included farm visits, clinical inspection of pigs, completion of farm management questionnaires, pathological tests into the cause of the diarrhoea and analysis of the non-starch polysaccharide (NSP) content of feeds. The results from 17 farms designated as NSC and 10 control farms suggest dietary associations with NSC. Farms with NSC fed diets with significantly higher levels of NSPs, especially containing the sugars glucose, arabinose and xylose. Few management factors were identified, although the high prevalence of infectious colitis reduced the power of the study.

Transfer of antibiotic resistance between commensal and pathogenic members of the Enterobacteriaceae under ileal conditions

AIM

To determine the rate of antibiotic resistance transmission between commensal and pathogenic representatives of the Enterobacteriaceae.

METHODS AND RESULTS

Through the use of a validated in vitro simulation of the porcine ileum, the transmission of antibiotic resistance was detected between commensal Escherichia coli, E. coli O157 and Salmonella spp. Countable transconjugant populations arose readily and, in one example, proved capable of indefinite persistence.

CONCLUSIONS

Genetic material conferring antibiotic resistance is readily transmissible between members of the Enterobacteriaceae under ileal conditions. Recipient phenotype influences the persistence of multi-resistant transconjugants.

SIGNIFICANCE AND IMPACT OF THE STUDY

The observation that the conjugal transmission of antibiotic resistance is commonplace under ileal conditions impacts primarily on the risk of food contamination by multi-resistant bacteria. The establishment of a multi-resistant transconjugant population as a dominant member of the microflora maintains a genetic reservoir of antimicrobial resistance.

The medical emergency team: does it really make a difference?

Hospital systems are failing the critically ill. This has been well documented in many countries around the world, with detailed reports of suboptimal care prior to intensive care and high rates of serious adverse events, including death. These events are potentially preventable, but insufficient attention has been directed towards developing solutions to these important problems to date. The medical emergency team (MET) is a system approach that promotes early and appropriate intervention in the care of critically ill hospital patients. The benefits of the MET in terms of absolute in-patient mortality and cardiac arrest rates are not yet well-defined, although preliminary studies are promising. The MET does provide a potentially beneficial impact on many other aspects of patient care. These benefits include: (i) facilitating an integrated and coordinated approach to patient care across the hospital, (ii) increasing awareness of at-risk patients, (iii) encouraging early referral of seriously ill patients to clinicians with expertise in critical care and (iv) providing a foundation for quality initiatives for hospital-wide care of the seriously ill. The MET also empowers nursing staff and junior medical staff to call for immediate assistance in cases where they are seriously concerned about a patient, but may not have the experience, knowledge, confidence or skills necessary to manage them appropriately.

Influence of tetracycline exposure on tetracycline resistance and the carriage of tetracycline resistance genes within commensal Escherichia coli populations

AIMS

To assess the influence of incremental tetracycline exposure on the genetic basis of tetracycline resistance within faecal Escherichia coli.

METHODS AND RESULTS

Through the adoption of a novel combination of multiple breakpoint selection, phenotypic characterization and the application of a polymerase chain reaction based gene identification system it proved possible to monitor the influence of antibiotic exposure on resistance gene possession. Using tetracycline as a case study a clear hierarchy was revealed between tet genes, strongly influenced by host antimicrobial exposure history.

CONCLUSIONS

The antimicrobial exposure regime under which an animal is produced affects both the identity and magnitude of resistance gene possession of a selected bacterial population within its enteric microflora. Among the ramifications associated with such resistance gene selection is the degree of resistance conferred and the carriage of linked resistance determinants. This selection is applied by exposure to antibiotic concentrations well below recognized minimum inhibitory tetracycline concentration breakpoints widely adopted to characterize bacterial 'susceptibility'.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study confirms the ability of minimal antibiotic exposure to select for the continued persistence of resistance genes within the enteric microflora. It is clearly demonstrated that different antimicrobial regimes select for different resistance genes, the implications of which are discussed.

Methane oxidation and its coupled electron-sink reactions in ruminal fluid

AIMS

This study was conducted to investigate the occurrence of methane oxidation in the rumen, and to identify the electron-sink reaction coupled to the oxidation if it occurred.

METHODS AND RESULTS

Mixed ruminal microbes taken from sheep were incubated with 13CH4. Oxidation of methane, estimated from the flux of 13C to CO2 and microbial cells, occurred, but represented only 0.2-0.5% of the methane produced. Methane oxidation was suppressed by the presence of oxygen, and was also inhibited by 2-bromoethane-sulphonate, and molybdate, but not by tungstate.

CONCLUSION, SIGNIFICANCE AND IMPACT OF THE STUDY

Methane could be oxidized anaerobically in the rumen by reverse methanogenesis in consort with sulphate reduction.

Quality of health services and early postpartum discharge: results from a sample of non-English-speaking women

Few studies have explored the knowledge, perceptions and satisfaction of ethnic women in relation to early obstetric discharge. The aim of this study was to form a profile of Vietnamese mothers who opt for early postpartum discharge, and to identify factors associated with those decisions. Focus group discussions, in-depth interviews and survey questionnaires were utilized to collect information from a sample of 160 mothers. Sixty mothers (38%) opted for early discharge (< 48 h). Factors strongly associated with early discharge were poor comprehension of English (OR=6.58, 95% CI=1.81, 24.02), very low level of education (OR=3.10, 95% CI=1.55, 6.20) and first time mother (OR=2.70, 95% CI=1.15, 4.27). The in-depth interviews identified further factors driving early discharge, including fear and anxiety when having to approach staff for assistance, and perceptions of disempowerment within culturally unfamiliar hospital surroundings. The findings in this study ought to alert administrators and clinicians to possible negative drivers for the choice of early postpartum discharge by Vietnamese mothers.

The Medical Emergency Team: 12 month analysis of reasons for activation, immediate outcome and not-for-resuscitation orders

OBJECTIVE

To describe the reasons for, and immediate outcome following Medical Emergency Team (MET) activation.

METHODS

Retrospective analysis of MET calls in 1998.

RESULTS

There were 713 MET calls to 559 in-patients. Of the 559 patients 252 (45%) were admitted to ICU and 49 (6.9%) died during the MET response. The three commonest criteria for calling the MET were a fall in GCS>2 (n=155); a systolic blood pressure<90 mmHg (n=142) and a respiratory rate>35 (n=109). Cardiac arrests accounted for 61 calls and had an immediate mortality of 59%. The most common MET criterion associated with admission to ICU was a respiratory rate >35. Of patients who received MET calls based only on the 'worried' criterion 16% were admitted to ICU. The MET felt that a not-for-resuscitation order would have been appropriate in 130 cases (23%). NFR orders were documented during 27 of the MET calls.

CONCLUSIONS

The MET system provides objective and subjective criteria by which medical and nursing staff can identify patients who become acutely unwell. A high proportion of these patients will require admission to Intensive Care. The MET system also provides the opportunity to identify patients for whom an NFR order should be considered.

A framework for monitoring maternal and infant health status

The Mother and Infant Network (MINET) Program was established in South Western Sydney Area Health Service(SWSAHS) in 1997. MINET developed and implemented an integrated clinical data network as a key strategy tosupport and inform a Continuum of Care comprising hospital and community based services. There are good datasources within the MINET program. Its scope spans care for mothers and children, which begins with the firstantenatal attendance and ends at school entry.This paper has three interrelated aims: to describe the development of the MINET program; to demonstrate thebenefits of a sustainable Information Culture which can assist an Area Health Services in adopting a health outcomesbased approach to service delivery; and to describe how MINET has the capacity to support Health Services Research.

Acute hospital medical staffing during the night shift

There has been little or no attempt to define the need for 24-hour medical cover, nor its appropriateness in acute hospitals, despite the great cost implications and the question of the quality of that care. This study examined the medical activity during the 'night shift' in an acute hospital. There were an average of 2.59 calls per night, most from the emergency department (247/475) and general wards (108/475). Many calls were related to active resuscitation (88/475) and immediate treatment (83/475). Over 40% (81/286) of patients had to be transferred to a higher level of care, such as an intensive care unit within the hospital. By collecting data on the demands of health care during what amounts to over a third of the hospital's time, it was established that a high level of medical care was required. Appropriate levels of staffing, using junior doctors trained in acute medicine, was able to be provided to match need as determined by these data, and extra staff at higher costs were avoided.

Intra-abdominal hypertension is an independent cause of postoperative renal impairment

HYPOTHESIS

Intra-abdominal hypertension exerts an effect on renal function independent of other confounding variables.

DESIGN

A prospective study of all patients admitted to an intensive care unit following abdominal surgery was undertaken between September 1, 1994, and July 31, 1997, in a single university hospital.

MAIN OUTCOME MEASURES

Intra-abdominal pressure (IAP) was measured every 8 hours (normal IAP, 0-17 mm Hg); 18 mm Hg or higher was considered increased. Forward stepwise logistic regression determined whether intra-abdominal hypertension is an independent cause of renal impairment.

RESULTS

A total of 263 patients (174 after emergency surgery), whose mean +/- SD age was 61.0 +/- 18.7 years and Acute Physiology and Chronic Health Evaluation II score was 14.6 +/- 7.7, were studied. Intra-abdominal pressure was increased in 107 (40.7%) of the 263 patients. Renal impairment occurred in 35 (32.7%) of the 107 patients with intra-abdominal hypertension and in 22 (14.1%) of the 156 with a normal IAP (odds ratio, 1.62-5.42). Using the Wald maximizing model, renal impairment was independently associated with 4 antecedent factors: hypotension (P= .09), sepsis (P = .006), age older than 60 years (P = .03), and increased IAP (P = .004).

CONCLUSIONS

To our knowledge, for the first time in a large clinical study, IAP has been shown to be an independent cause of renal impairment, and it ranks in importance after hypotension, sepsis, and age older than 60 years. Surgeons need to be aware of the importance of intra-abdominal hypertension in patients postoperatively.

Temporary abdominal closure: a prospective evaluation of its effects on renal and respiratory physiology

This study prospectively analyzed outcomes in 49 consecutive patients undergoing temporary abdominal closure (TAC) between 1993 and 1996 at a single university hospital. There were 37 males and 12 females, mean age was 57 years (range, 25-79 years), mean Acute Physiology and Chronic Health Evaluation score was 27 (+7.8 SD), and mean Simplified Acute Physiology II score was 53.0 (+/-15.4). The reason for TAC was decompression in 22 patients, inability to close the abdomen in 10 patients, to facilitate reexploration for sepsis in 8 patients, and multifactorial in 9 patients. After TAC, there was a significant reduction in intra-abdominal pressure from 24.2+/-9.3 to 14.1+/-5.5 mm Hg and improvement in lung dynamic compliance from 24.1+/-7.9 to 27.6+/-9.4 mL/cm H2O (p < 0.05). Although 10 patients experienced brisk diuresis, there was no significant improvement in renal function; in fact, serum creatinine increased. The median length of stay was 35 days (range, 1-232 days). The mean number of abdominal operations after mesh insertion was 2.6+/-2.4. There were 21 deaths, for a standardized mortality rate of 0.80. Although it achieved significant reductions in abdominal pressures and improved lung dynamic compliance, TAC did not result in improved renal function or patient oxygenation.

Psychiatric morbidity following motor vehicle accidents: a review of methodological issues

Motor vehicle accidents (MVAs), even those of a nonserious nature, appear to increase the risk of severe psychiatric morbidity in survivors. The present review examines the evidence indicating the levels of psychiatric morbidity in MVA survivors. Although no consistent profile has emerged, the most commonly reported symptoms are depression, anxiety, irritability, driving phobia, anger, sleep disturbances, and headache, with rates of posttraumatic stress disorder (PTSD) across studies of 0% to 100%. Variability in the type and severity of psychiatric outcomes may be due, in part, to methodological inadequacies in many studies, particularly the use of biased population samples, inclusion of subjects exposed to varied types of accidents, an absence of a clear definition of PTSD, a reliance on clinical judgment rather than the use of objective psychometric measures, the failure to include ratings of injury severity, and the absence of assessments for past exposure to traumatic events or preexisting posttraumatic reactions. The most important concern relates to the use of nonrepresentative samples, usually patients referred for medicolegal assessment in whom issues of compensation are of central importance. Gender and age differences distinguish the compensation group from the general population of MVA survivors, who therefore may also differ in the vulnerability to posttraumatic morbidity. It is argued that more systematic research on unselected subject samples is critical to establish epidemiological data on the true nature and extent of psychiatric morbidity following MVAs.

Quality of life outcomes after intensive care. Comparison with a community group

OBJECTIVE

Compare the health related quality of life of intensive care patients with a community sample.

DESIGN

Self-completed questionnaire posted to a consecutive sample of 238 patients 16 months after discharge from an intensive care unit (ICU) and to a random community sample (n = 242).

SETTING

The Liverpool Hospital is the main referral and teaching hospital in a community of 620,000 people. It has a ten-bed general ICU.

PATIENTS AND PARTICIPANTS

All patients admitted to the ICU over 8 months with a length of stay > or = 24 h and a sample drawn from the community telephone directory.

MEASUREMENTS AND MAIN RESULTS

The self completed questionnaire contained physical and psychosocial health and quality of life (QOL) scales. Analysis of variance indicated that ICU patients were more physically ill and anxiously depressed than the community sample. Sixty-three per cent of patients had not attained full health, were functionally impaired and had a poorer QOL than those patients who had returned to full health and the community. Psychosocial health (apart from anxious depression) was related to the level of perceived physical health rather than to whether or not they had been admitted to the ICU. Those subjects not in full health had poorer interpersonal relationships, less positive attitudes about life, more anxious depression and more suicidal depression.

CONCLUSIONS

ICU patients following discharge have worse perceived health and more anxiety than others in the community. Sixty-three per cent of patients had a poorer QOL and functional health than those who returned to full health and those in the community.

Intraabdominal pressure and gastric intramucosal pH: is there an association?

This study evaluated the potential association between increased intraabdominal pressure (IAP) and abnormally low gastric intramucosal pH (pHi) (</= 7.32) in postoperative patients and assessed its effect on patient outcome. Altogether 73 patients undergoing major abdominal surgery over a 9-month period were studied prospectively. All underwent gastric tonometry and intravesical IAP measurements three time daily. An IAP of >/= 20 mmHg and a pHi of </= 7.32 were considered abnormal. The development of the following complications were also documented: hypotension [mean aortic pressure (MAP) < 80 mmHg], abdominal sepsis, renal impairment, and death. The median APACHE II score was 16 (range 5-34). Twenty-two patients had upper gastrointestinal (GI) surgery, 27 lower GI surgery, and 24 aortic surgery; 44 of these patients underwent emergency surgery. Abnormal pHi (</= 7.32) occurred in 36 patients while on the intensive care unit. Compared to patients with normal pHi, abnormal pHi patients were 11.3 times (3.2-43.5) [odds ratio +/- 95% CI] more likely to have an increased IAP. Abnormal pHi was significantly associated with hypotension (chi2 = 6.8;p = 0.009), sepsis (chi2 = 3.7;p = 0.06), renal impairment (chi2 = 28.3;p = 0. 0000001), relaparotomy (chi2 = 4.1;p = 0.04), and death (chi2 = 9. 7;p = 0.002). This study demonstrated a significant clinical association between increased IAP and abnormal pHi. An abnormally low pHi was associated with poor outcome.