Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Translational potential of a mouse in vitro bioassay in predicting gastrointestinal adverse drug reactions in Phase I clinical trials

BACKGROUND

Motility-related gastrointestinal (GI) adverse drug reactions (GADRs) such as diarrhea and constipation are a common and deleterious feature associated with drug development. Novel biomarkers of GI function are therefore required to aid decision making on the GI liability of compounds in development.

METHODS

Fifteen compounds associated with or without clinical GADRs were used to assess the ability of an in vitro colonic motility bioassay to predict motility-related GADRs. Compounds were examined in a blinded fashion for their effects on mouse colonic peristaltic motor complexes in vitro. For each compound concentration-response relationships were determined and the results compared to clinical data. Compounds were also assessed using GI transit measurements obtained using an in vivo rat charcoal meal model.

KEY RESULTS

Within a clinically relevant dosing range, the in vitro assay identified five true and three false positives, four true and three false negatives, which gave a predictive capacity of 60%. The in vivo assay detected four true and four false positives, four false and three true negatives, giving rise to a predictive capacity for this model of 47%.

CONCLUSIONS & INFERENCES

Overall these results imply that both assays are poor predictors of GADRs. Further analysis would benefit from a larger compound set, but the data show a clear need for improved models for use in safety pharmacology assessment of GI motility.

Where do AMU nurses perceive their educational needs? Results of the 20:10 project

Our aim was to identify the perceived educational needs of nurses working in acute medicine to enable development of a training curriculum specifically for this staff group.

METHODS

Post-graduate nurses from North Wales were invited to list 20 conditions and 10 skills for which they felt under prepared for their work in acute medicine. A workshop was then organized, attended by acute medicine nurses, medical colleagues and educationalists from two local universities to discuss initial data.

RESULTS

Nurses identified particular needs for education around presenting symptoms with perceived deficits in knowledge or training. We found a heavy emphasis on respiratory and cardiac conditions. There was considerable overlap with frequent diagnostic categories from non-surgical hospital discharges and with priorities for training of junior doctors. Skills were often those traditionally associated with medical staff or care of patients with critical illnesses.

CONCLUSION

The 20:10 project represents the first attempt to map educational needs of nursing staff on the Acute Medical Units of a large University Health Board using self-reported needs. The identified needs will support professional development, create incentives for recruitment and guide University postgraduate developments and commissioning.

Pathways to fitness for practice: National Vocational Qualifications as a foundation of competence in nurse education

Nurse education is currently undergoing major change. This article seeks to examine how National Vocational Qualifications (NVQs) are contributing to the future of nurse education. Criticisms of Project 2000 (P2K) include failure of the programme to produce nurses who are 'fit for practice' at the point of registration. A major criticism was that there is not enough skills-based training included. Following a recent report, recommendations were made which included a move to introduce a competence-based approach in nurse education. This approach is becoming more evident in both pre- and post-registration nurse education. A mapping exercise demonstrated that many of the UKCC competencies for pre-registration nurse education could be mapped to care NVQs. The article concludes that the positive aspects of care NVQs and P2K education should be embraced to enable programmes of nurse education to prepare nurses who are 'fit for practice'.

The role of the midwife in perineal wound care following childbirth

Midwives have an important role to play in the care of perineal wounds following childbirth. A wide variety of practices are carried out in this area. However, some current practices may not be beneficial to the promotion of wound healing. Midwives must realize the relevance of their care and potential impact, both positive and negative, of advocated treatments in wound healing. The maintenance of effective pain relief must be balanced with the need to promote wound healing. It is important that midwives recognize the need for research-based practice and that an audit is set up nationally to evaluate the efficacy of treatments and practice. Research, audit and evaluation of services are the central processes involved in providing effective and efficient care, as advocated by the Department of Health (1993).