Mapping Processes in the Emergency Department Using the Functional Resonance Analysis Method

Emergency departments (EDs) are dynamic, complex, and demanding environments. Introducing changes that lead to improvements in EDs can be challenging owing to the high staff turnover and mix, high patient volume with different needs, and being the front door to the hospital for the sickest patients. Quality improvement is a methodology applied routinely in EDs to instigate change to improve several outcomes such as waiting times, time to definitive treatment, and patient safety. Introducing the changes needed to transform the system in this way is seldom straightforward with the risk of "not seeing the forest for the trees" when attempting to change the system. In this article, we demonstrate how the functional resonance analysis method can be used to capture the experiences and perceptions of frontline staff to identify the key functions in the system (the trees), to understand the interactions and dependencies between them to make up the ED ecosystem ("the forest") and to support quality improvement planning, identifying priorities and patient safety risks.

Mitigating bias in estimating epidemic severity due to heterogeneity of epidemic onset and data aggregation

Outbreaks of infectious diseases, such as influenza, are a major societal burden. Mitigation policies during an outbreak or pandemic are guided by the analysis of data of ongoing or preceding epidemics. The reproduction number, R0, defined as the expected number of secondary infections arising from a single individual in a population of susceptibles is critical to epidemiology. For typical compartmental models such as the Susceptible-Infected-Recovered (SIR) R0 represents the severity of an epidemic. It is an estimate of the early-stage growth rate of an epidemic and is an important threshold parameter used to gain insights into the spread or decay of an outbreak. Models typically use incidence counts as indicators of cases within a single large population; however, epidemic data are the result of a hierarchical aggregation, where incidence counts from spatially separated monitoring sites (or sub-regions) are pooled and used to infer R0. Is this aggregation approach valid when the epidemic has different dynamics across the regions monitored? We characterize bias in the estimation of R0 from a merged data set when the epidemics of the sub-regions, used in the merger, exhibit delays in onset. We propose a method to mitigate this bias, and study its efficacy on synthetic data as well as real-world influenza and COVID-19 data.

Acute Hydrothorax Complicating Peritoneal Dialysis

Aim

To determine whether gradually increasing the peritoneal dialysate fill volume from 10 to 40 mL/kg over 6 days, rather than commencing at 40 mL/kg, prevents hydrothorax in children and reverses it if present.

Methods

A review of children peritoneally dialyzed in a single center.

Results

During the 20 years beginning June 1985, 416 children were peritoneally dialyzed, of which 327 (79%) had acute and 89 had end-stage renal failure. Among 253 children who had gradually increasing fill volumes, none developed acute hydrothoraces, but 13/163 (8%) who began with 40 mL/kg cycles did ( p < 0.000, Fisher's exact test). These were diagnosed after a median (range) of 48 (6 – 72) hours and were predominantly right sided. Initially, we readily abandoned peritoneal dialysis; 2 were changed to hemodialysis. Subsequently, we found that peritoneal dialysis could be continued by using small volumes with the patients sitting up; cycle volumes were then gradually increased again. One pre-term baby died soon after developing an acute hydrothorax. One patient on chronic peritoneal dialysis developed an acute hydrothorax after forceful vomiting, but recovered after being dialyzed sitting up with low fills.

Conclusion

Acute hydrothorax can be prevented and treated using graduated cycle volumes, and is not a contraindication for peritoneal dialysis.

Positive trends in paediatric renal biopsy service provision in the UK: a national survey and re-audit of paediatric renal biopsy practice

BACKGROUND

Paediatric renal biopsy standards introduced in the UK in 2010 were intended to reduce variation and improve practice. A concurrent national drive was aimed at building robust paediatric nephrology networks to ensure services cater for the needs of the family and minimise time away from home. We aimed to identify current national practice since these changes on behalf of the British Association for Paediatric Nephrology.

METHODS

All UK paediatric nephrology centres were invited to complete a survey of their biopsy practice, including advance preparation. From 1 January to 30 June 2012, a national prospective audit of renal biopsies was undertaken at participating centres comparing practice with the British Association for Paediatric Nephrology (BAPN) standards and audit results from 2005.

RESULTS

Survey results from 11 centres demonstrated increased use of pre-procedure information leaflets (63.6 % vs 45.5 %, P = 0.39) and play preparation (90.9 % vs 9.1 %, P = 0.0001). Audit of 331 biopsies showed a move towards day-case procedures (49.5 % vs 32.9 %, P = 0.17) and reduced major complications (4.5 % vs 10.4 %, P = 0.002). Biopsies with 18-gauge needles had significantly higher mean pass rates (3.2 vs 2.3, P = 0.0008) and major complications (15.3 % vs 3.3 %, P = 0.0015) compared with 16-gauge needles.

CONCLUSIONS

Percutaneous renal biopsy remains a safe procedure in children, thus improving family-centered service provision in the UK.

Minimising changes in plasma calcium and magnesium concentrations during plasmapheresis

Hypocalcaemic tetany is a known complication of plasmapheresis. It has two causes. Intravenously administered 4.5% human albumin solution (HAS) has no calcium or magnesium, so the replacement of plasma with this fluid depletes these ions. The citrate in fresh frozen plasma (FFP) chelates divalent cations, so the exchange with this at the end reduces the proportion of calcium and magnesium that is ionised. We studied the effect of supplementing HAS with 2 mmol/l calcium chloride and 0.8 mmol/l magnesium sulphate on the changes in ionised and total calcium and magnesium concentrations throughout plasmapheresis. The supplements prevented the falls in these concentrations that is otherwise seen during the HAS infusion, and, thus, the transient fall in ionised calcium concentration induced by the citrate in the FFP was not so profound, reaching 0.92 instead of 0.78 mmol/l (P = 0.002). Supplementation with calcium and magnesium during HAS maintains their balance and prevents tetany during the FFP infusion.

Acute hydrothorax complicating peritoneal dialysis

AIM

To determine whether gradually increasing the peritoneal dialysate fill volume from 10 to 40 mL/kg over 6 days, rather than commencing at 40 mL/kg, prevents hydrothorax in children and reverses it if present.

METHODS

A review of children peritoneally dialyzed in a single center.

RESULTS

During the 20 years beginning June 1985, 416 children were peritoneally dialyzed, of which 327 (79%) had acute and 89 had end-stage renal failure. Among 253 children who had gradually increasing fill volumes, none developed acute hydrothoraces, but 13/163 (8%) who began with 40 mL/kg cycles did (p < 0.000, Fisher's exact test). These were diagnosed after a median (range) of 48 (6-72) hours and were predominantly right sided. Initially, we readily abandoned peritoneal dialysis; 2 were changed to hemodialysis. Subsequently, we found that peritoneal dialysis could be continued by using small volumes with the patients sitting up; cycle volumes were then gradually increased again. One pre-term baby died soon after developing an acute hydrothorax. One patient on chronic peritoneal dialysis developed an acute hydrothorax after forceful vomiting, but recovered after being dialyzed sitting up with low fills.

CONCLUSION

Acute hydrothorax can be prevented and treated using graduated cycle volumes, and is not a contraindication for peritoneal dialysis.

Tissue plasminogen activator for blocked peritoneal dialysis catheters

Tissue plasminogen activator was used for a blocked peritoneal dialysis catheter in a child with no vascular access. The catheter was salvaged using tissue plasminogen activator and dialysis could be carried out without any difficulty.

Recombinant human erythropoietin therapy for treatment of anemia of prematurity in very low birth weight infants: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the efficacy and safety of recombinant human erythropoietin (rHuEPO) in very low birth weight infants with anemia of prematurity.

STUDY DESIGN

Thirty infants were randomly assigned to receive either rHuEPO (300 U/kg per dose) or placebo twice a week. Hematologic parameters, transfusion requirements, caloric intake, and growth were monitored.

RESULTS

The number and volume of erythrocyte transfusions were significantly lower in infants treated with rHuEPO. Serum ferritin levels, similar in both groups at study entry, fell and were significantly lower in rHuEPO-group infants at the completion of the study. An inverse correlation was observed between reticulocyte count and absolute neutrophil count both at entry and at completion of the study.

CONCLUSION

Twice-a-week administration of rHuEPO significantly reduces the need for erythrocyte transfusion in very low birth weight infants in stable condition. A significant decrease in serum ferritin levels in infants receiving rHuEPO suggests the need to determine the optimal dose of iron supplementation in these infants.