This document summarizes an article about how clinical informatics tools can help make patient consultations more efficient. It provides guidelines for assessing the severity of asthma exacerbations in children and outlines the steps for acute asthma management in an emergency department. Recording clinical data from patient encounters enables clinicians to better understand local service needs, compare performance to other health systems, and continuously improve care over time.
Dexmedetomidine is a selective alpha-2 adrenergic receptor agonist used for sedation in the ICU. It provides "cooperative sedation" allowing easy patient awakening and assessment. Studies show dexmedetomidine reduces delirium and time on ventilators compared to midazolam and propofol. The most common side effects are hypotension and bradycardia. Dexmedetomidine has potential benefits for treating agitation, delirium, alcohol withdrawal syndrome, and may reduce opioid needs and cardiovascular risks in ICU patients.
The document summarizes the properties and clinical uses of dexmedetomidine, a highly selective alpha-2 adrenergic receptor agonist. It was first synthesized in the 1980s and approved by the FDA in 1999 for sedation in intensive care units. Dexmedetomidine has sedative, anxiolytic, and analgesic effects. It provides a unique sedation state resembling natural sleep and reduces opioid requirements. Clinical trials demonstrate dexmedetomidine results in shorter ICU and ventilator times compared to midazolam. Adverse effects include hypotension and bradycardia. The document reviews the pharmacokinetics, mechanisms of action, clinical effects, indications and trials of dexmedetomidine
The New 2018 SCCM PADIS Guidelines: Quick Hits of Recommendations for Sedatio...Intensive Care Society
Dr. Needham is Professor of Pulmonary and Critical Care Medicine, and of Physical Medicine and Rehabilitation at the Johns Hopkins University in Baltimore, USA. He is Director of the “Outcomes After Critical Illness and Surgery” (OACIS) Research Group and core faculty with the Armstrong Institute for Patient Safety and Quality, both at Johns Hopkins. From a clinical perspective, he is an attending physician in the medical intensive care unit at Johns Hopkins Hospital and Medical Director of the Johns Hopkins Critical Care Physical Medicine and Rehabilitation program.
Dr. Needham received his MD degree from McMaster University in Hamilton, Canada, and completed both his residency in internal medicine and his fellowship in critical care medicine at the University of Toronto. He obtained his PhD in Clinical Investigation from the Bloomberg School of Public Health at Johns Hopkins University. Notably, prior to his medical training, he completed Bachelor and Master degrees in Accounting and practiced in a large international accounting firm, with a focus in the health care field.
Dr. Needham is Principal Investigator on a number of NIH research grants and has authored more than 250 publications. His research interests include evaluating and improving ICU patients’ long-term physical, cognitive and mental health outcomes, including research in the areas of sedation, delirium, early physical rehabilitation, and knowledge translation and quality improvement.
1. The document reviews pharmacologic management in palliative care, focusing on common symptoms, medications used, and opioid management.
2. Common symptoms in terminal illness include fatigue, pain, delirium, dyspnea, nausea, depression, and insomnia. Opioids are often used off-label in palliative care based on experience rather than evidence.
3. The document provides guidance on assessing pain, converting between opioids, managing breakthrough pain and side effects, and using adjunctive medications for symptoms like nausea and dyspnea. Non-pharmacologic approaches are also emphasized.
Precedex is an alpha-2 agonist sedative that provides sedation, anxiolysis, and analgesia with minimal respiratory depression. It can be used in minor procedures not requiring intubation to reduce anesthesia needs and help keep patients calm during induction and emergence from anesthesia. Precedex decreases the stress response to trauma by inhibiting the sympathetic nervous system and reducing cardiovascular changes like tachycardia and hypertension. Common side effects include hypotension, bradycardia, and dry mouth. It has few drug interactions and is metabolized in the liver with a terminal half-life of about 2 hours.
This document discusses sedation practices in the ICU. It covers topics like sedation scores, problems with over and under sedation, pharmacology of sedative drugs, delirium monitoring and prevention. It recommends using non-benzodiazepine sedatives like propofol and dexmedetomidine for short-term sedation. Maintaining a light level of sedation, daily sedation holidays, adequate pain relief and early mobilization are emphasized to improve outcomes. Valid sedation scales like RASS and SAS should be used and documented regularly.
sedation in neuro icu requires frequent interruptions for serial neurological examination. incorporation of inhalational agents in icu improves sedation practices.
Dexmedetomidine is a selective alpha-2 adrenergic receptor agonist used for sedation in the ICU. It provides "cooperative sedation" allowing easy patient awakening and assessment. Studies show dexmedetomidine reduces delirium and time on ventilators compared to midazolam and propofol. The most common side effects are hypotension and bradycardia. Dexmedetomidine has potential benefits for treating agitation, delirium, alcohol withdrawal syndrome, and may reduce opioid needs and cardiovascular risks in ICU patients.
The document summarizes the properties and clinical uses of dexmedetomidine, a highly selective alpha-2 adrenergic receptor agonist. It was first synthesized in the 1980s and approved by the FDA in 1999 for sedation in intensive care units. Dexmedetomidine has sedative, anxiolytic, and analgesic effects. It provides a unique sedation state resembling natural sleep and reduces opioid requirements. Clinical trials demonstrate dexmedetomidine results in shorter ICU and ventilator times compared to midazolam. Adverse effects include hypotension and bradycardia. The document reviews the pharmacokinetics, mechanisms of action, clinical effects, indications and trials of dexmedetomidine
The New 2018 SCCM PADIS Guidelines: Quick Hits of Recommendations for Sedatio...Intensive Care Society
Dr. Needham is Professor of Pulmonary and Critical Care Medicine, and of Physical Medicine and Rehabilitation at the Johns Hopkins University in Baltimore, USA. He is Director of the “Outcomes After Critical Illness and Surgery” (OACIS) Research Group and core faculty with the Armstrong Institute for Patient Safety and Quality, both at Johns Hopkins. From a clinical perspective, he is an attending physician in the medical intensive care unit at Johns Hopkins Hospital and Medical Director of the Johns Hopkins Critical Care Physical Medicine and Rehabilitation program.
Dr. Needham received his MD degree from McMaster University in Hamilton, Canada, and completed both his residency in internal medicine and his fellowship in critical care medicine at the University of Toronto. He obtained his PhD in Clinical Investigation from the Bloomberg School of Public Health at Johns Hopkins University. Notably, prior to his medical training, he completed Bachelor and Master degrees in Accounting and practiced in a large international accounting firm, with a focus in the health care field.
Dr. Needham is Principal Investigator on a number of NIH research grants and has authored more than 250 publications. His research interests include evaluating and improving ICU patients’ long-term physical, cognitive and mental health outcomes, including research in the areas of sedation, delirium, early physical rehabilitation, and knowledge translation and quality improvement.
1. The document reviews pharmacologic management in palliative care, focusing on common symptoms, medications used, and opioid management.
2. Common symptoms in terminal illness include fatigue, pain, delirium, dyspnea, nausea, depression, and insomnia. Opioids are often used off-label in palliative care based on experience rather than evidence.
3. The document provides guidance on assessing pain, converting between opioids, managing breakthrough pain and side effects, and using adjunctive medications for symptoms like nausea and dyspnea. Non-pharmacologic approaches are also emphasized.
Precedex is an alpha-2 agonist sedative that provides sedation, anxiolysis, and analgesia with minimal respiratory depression. It can be used in minor procedures not requiring intubation to reduce anesthesia needs and help keep patients calm during induction and emergence from anesthesia. Precedex decreases the stress response to trauma by inhibiting the sympathetic nervous system and reducing cardiovascular changes like tachycardia and hypertension. Common side effects include hypotension, bradycardia, and dry mouth. It has few drug interactions and is metabolized in the liver with a terminal half-life of about 2 hours.
This document discusses sedation practices in the ICU. It covers topics like sedation scores, problems with over and under sedation, pharmacology of sedative drugs, delirium monitoring and prevention. It recommends using non-benzodiazepine sedatives like propofol and dexmedetomidine for short-term sedation. Maintaining a light level of sedation, daily sedation holidays, adequate pain relief and early mobilization are emphasized to improve outcomes. Valid sedation scales like RASS and SAS should be used and documented regularly.
sedation in neuro icu requires frequent interruptions for serial neurological examination. incorporation of inhalational agents in icu improves sedation practices.
Pain and Sedation in Critically Ill PatientsAllison Boyd
This document discusses pain and sedation management in critically ill patients. It provides an overview of non-pharmacologic and pharmacologic strategies for pain, including acetaminophen, ketamine, gabapentin, lidocaine, ketorolac, and various opioid analgesics. Dosing, mechanisms of action, and safety considerations are reviewed for different analgesic options. Guidelines for outpatient opioid prescribing upon discharge from the ICU are also mentioned.
Global Bridges: Pharmacotherapy for Tobacco DependenceGlobal Bridges
May 2012: Dr. Richard Hurt, director of the Nicotine Dependence Center at the Mayo Clinic and chair of Global Bridges: Healthcare Alliance for Tobacco Dependence Treatment, discusses pharmacotherapy for tobacco dependence at a workshop in Jamaica.
The document discusses agitation, sedation, delirium, and pain management in critically ill patients. It describes the Richmond Agitation and Sedation Scale (RASS) used to assess sedation levels in the ICU. Light sedation is preferred to deep sedation. Spontaneous awakening and breathing trials should occur daily. Propofol and dexmedetomidine are preferred sedatives over benzodiazepines. Delirium is common in ICU patients and associated with poor outcomes. The Confusion Assessment Method for the ICU (CAM-ICU) is used to assess for delirium. A stepwise approach including identifying and eliminating contributing factors, implementing non-pharmacologic therapies, and pharmacologic management
Treating Agitation and De to an Alphabet Soup of Potential Optionshospira2010
1) The MINDS trial compared haloperidol to placebo for treatment of delirium in mechanically ventilated ICU patients and found no difference in the number of delirium/coma-free days between the two groups.
2) Haloperidol treatment did not reduce the duration of delirium or coma compared to placebo.
3) There was no evidence from this randomized controlled trial that haloperidol is effective for treating delirium in critically ill patients.
Major depressive disorder (MDD) affects approximately 14 million adults in the United States, though only around 7 million receive treatment. Current antidepressant medications are ineffective for many patients, leaving around 4 million people with MDD poorly served. Transcranial magnetic stimulation (TMS) therapy using the NeuroStar TMS System offers an alternative treatment option that works via a different mechanism of action than antidepressants to target underlying brain circuits involved in mood regulation without systemic side effects.
This systematic review and meta-analysis of 12 randomized clinical trials with over 7,000 patients compared outcomes of percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) in patients with stable coronary artery disease over a mean follow-up of 4.9 years. The analysis found no significant differences in all-cause mortality, cardiovascular death, nonfatal heart attack, or need for revascularization between PCI and OMT. Patients who received PCI had greater freedom from chest pain symptoms compared to those receiving OMT alone. The review indicates that PCI does not provide additional clinical benefits over OMT for stable coronary artery disease patients, though it may improve chest pain.
Injectable psychotropic medications may decrease relapse and rehospitalization rates compared to oral medications for patients aged 18-65 with schizophrenia. Dorothy Johnson's behavioral systems nursing model supports using long-acting injectables to prevent relapse by maintaining effective behavioral functioning. Several studies found decreased rehospitalization and improved outcomes with long-acting injectable antipsychotics compared to oral medications. However, increased use of injectables also decreases patient choice and agency over their own treatment. Nurses need to consider patients' and ethical implications regarding preferred treatment methods.
"If you don't take a temperature, you can't find a fever...(The House of God)" James Sartain cleverly uses case studies to highlight attitudes, issues and management of acute pain in ICUs. He'll make you think as he uncovers the discrepancies between guidelines and clinical practice. This podcast was recorded at BCC4.
1) The study compared the effects of carvedilol and atenolol on plasma noradrenaline levels at rest and during exercise in healthy volunteers.
2) Both drugs similarly reduced heart rate and blood pressure at rest and during exercise.
3) However, only carvedilol significantly blunted the rise in plasma noradrenaline during exercise, suggesting it has sympathoinhibitory effects that atenolol does not share.
4) This property of carvedilol may provide additional benefits for patients with heart failure over selective beta-blockers like atenolol.
Educação on-line envolve o uso da tecnologia para conectar professores e alunos que não estão fisicamente juntos, permitindo a interatividade através de ferramentas como e-mail e fóruns. Professores fornecem orientação e materiais didáticos online, enquanto alunos podem estudar e pesquisar em seu próprio tempo antes de completar atividades. Embora o acesso desigual e falta de preparação possam ser desafios, a educação on-line permite que pessoas completem graduações, mestrados e
O documento é um horário escolar para a Escola Secundária D. Inês de Castro em Alcobaça, Portugal. Ele lista os professores e as salas de aula para as aulas de História nas segundas, quartas, quintas e sextas-feiras entre 14:45-18:00 no ano letivo de 2010-2011.
Este documento descreve uma sessão de formação sobre práticas e modelos de autoavaliação de bibliotecas escolares. Os objetivos da sessão incluíram identificar instrumentos de avaliação e extrair evidências deles, formular declarações avaliativas e operacionalizar ações de melhoria. As tarefas propostas incluíram analisar instrumentos de avaliação e selecionar indicadores, escrever declarações avaliativas hipotéticas e propor uma ação de melhoria. A maioria dos participantes completou as tarefas com discussões prod
Hireko Golf Sales and Marketing WebinarHireko Golf
VP Marketing Rob Altomonte gives a sales and marketing presentation on how to make money selling Hireko Golf Clubs. View the audio portion on youtube.com/hirekogolf
O documento discute objetos de aprendizagem (OA), definindo-os como qualquer instrumento que pode ser utilizado e reutilizado para transmitir conteúdo educacional. Explica que OAs podem ser digitais ou não digitais e que sua reutilização reduz custos ao permitir compartilhamento. Também lista alguns repositórios de OAs e ferramentas como o Hot Potatoes que podem ser usadas para criar atividades digitais.
1. The patient care plan outlines criteria for discontinuing mechanical ventilation including maintaining normal ABG levels and keeping indwelling devices intact until discontinued.
2. It identifies potential nursing problems related to mechanical ventilation like alterations in cognitive function from medications or unfamiliar environment. Expected outcomes include returning to baseline mental status and understanding intubation needs.
3. Weaning procedures are described including slow, moderate, and quick methods and criteria for extubating based on assessment of respiratory effort and readiness.
This document defines and describes levels of sedation, from minimal to general anesthesia. It discusses behaviour management techniques, pharmacological and non-pharmacological approaches to sedation. Specific agents that can be used for sedation are outlined, including nitrous oxide, desflurane, sevoflurane, hydroxyzine, promethazine, diazepam, meperidine, ketamine, midazolam and propofol. Their indications, benefits, limitations and risks are provided. Guidelines for preparing for and administering sedation are also reviewed.
This document discusses the pharmacotherapy of bronchial asthma. It begins by classifying asthma and outlining its pathophysiology. It then describes various routes of drug administration, focusing on inhaled delivery methods like metered dose inhalers and nebulizers. The document details the management of asthma through both non-pharmacological and pharmacological approaches. It provides an overview of the main drug classes used to treat asthma, including beta-2 agonists, anticholinergics, methylxanthines, corticosteroids, and others. For each class, it outlines examples of drugs, their mechanisms of action, uses, dosages, and side effects.
Updates On Pharmacological Management Of Asthma In AdultsAshraf ElAdawy
The document provides information on pharmacological management of asthma in adults. It defines asthma as a chronic inflammatory airway disease characterized by airway inflammation, obstruction, and hyperresponsiveness. The diagnosis is clinical based on symptoms such as wheezing and tightness. Asthma is caused by airway inflammation and management aims to control inflammation and symptoms. Treatment involves anti-inflammatory controllers such as inhaled corticosteroids and relievers for symptoms. A stepwise treatment approach is used starting with relievers and adding preventers as needed to gain control.
RSI is a method of intubating patients who have a gag reflex who would otherwise be difficult to intubate. Intubation is accomplished by sedating and paralyzing the patient, allowing for easier intubation.
The document discusses procedural sedation, including definitions of different levels of sedation, monitoring requirements, safety considerations, common sedating agents like nitrous oxide, midazolam, fentanyl and their properties, and discharge criteria after a procedure. Procedural sedation involves administering sedatives to induce a depressed level of consciousness while maintaining cardiorespiratory function to allow medical procedures with little patient reaction or memory.
Pain and Sedation in Critically Ill PatientsAllison Boyd
This document discusses pain and sedation management in critically ill patients. It provides an overview of non-pharmacologic and pharmacologic strategies for pain, including acetaminophen, ketamine, gabapentin, lidocaine, ketorolac, and various opioid analgesics. Dosing, mechanisms of action, and safety considerations are reviewed for different analgesic options. Guidelines for outpatient opioid prescribing upon discharge from the ICU are also mentioned.
Global Bridges: Pharmacotherapy for Tobacco DependenceGlobal Bridges
May 2012: Dr. Richard Hurt, director of the Nicotine Dependence Center at the Mayo Clinic and chair of Global Bridges: Healthcare Alliance for Tobacco Dependence Treatment, discusses pharmacotherapy for tobacco dependence at a workshop in Jamaica.
The document discusses agitation, sedation, delirium, and pain management in critically ill patients. It describes the Richmond Agitation and Sedation Scale (RASS) used to assess sedation levels in the ICU. Light sedation is preferred to deep sedation. Spontaneous awakening and breathing trials should occur daily. Propofol and dexmedetomidine are preferred sedatives over benzodiazepines. Delirium is common in ICU patients and associated with poor outcomes. The Confusion Assessment Method for the ICU (CAM-ICU) is used to assess for delirium. A stepwise approach including identifying and eliminating contributing factors, implementing non-pharmacologic therapies, and pharmacologic management
Treating Agitation and De to an Alphabet Soup of Potential Optionshospira2010
1) The MINDS trial compared haloperidol to placebo for treatment of delirium in mechanically ventilated ICU patients and found no difference in the number of delirium/coma-free days between the two groups.
2) Haloperidol treatment did not reduce the duration of delirium or coma compared to placebo.
3) There was no evidence from this randomized controlled trial that haloperidol is effective for treating delirium in critically ill patients.
Major depressive disorder (MDD) affects approximately 14 million adults in the United States, though only around 7 million receive treatment. Current antidepressant medications are ineffective for many patients, leaving around 4 million people with MDD poorly served. Transcranial magnetic stimulation (TMS) therapy using the NeuroStar TMS System offers an alternative treatment option that works via a different mechanism of action than antidepressants to target underlying brain circuits involved in mood regulation without systemic side effects.
This systematic review and meta-analysis of 12 randomized clinical trials with over 7,000 patients compared outcomes of percutaneous coronary intervention (PCI) versus optimal medical therapy (OMT) in patients with stable coronary artery disease over a mean follow-up of 4.9 years. The analysis found no significant differences in all-cause mortality, cardiovascular death, nonfatal heart attack, or need for revascularization between PCI and OMT. Patients who received PCI had greater freedom from chest pain symptoms compared to those receiving OMT alone. The review indicates that PCI does not provide additional clinical benefits over OMT for stable coronary artery disease patients, though it may improve chest pain.
Injectable psychotropic medications may decrease relapse and rehospitalization rates compared to oral medications for patients aged 18-65 with schizophrenia. Dorothy Johnson's behavioral systems nursing model supports using long-acting injectables to prevent relapse by maintaining effective behavioral functioning. Several studies found decreased rehospitalization and improved outcomes with long-acting injectable antipsychotics compared to oral medications. However, increased use of injectables also decreases patient choice and agency over their own treatment. Nurses need to consider patients' and ethical implications regarding preferred treatment methods.
"If you don't take a temperature, you can't find a fever...(The House of God)" James Sartain cleverly uses case studies to highlight attitudes, issues and management of acute pain in ICUs. He'll make you think as he uncovers the discrepancies between guidelines and clinical practice. This podcast was recorded at BCC4.
1) The study compared the effects of carvedilol and atenolol on plasma noradrenaline levels at rest and during exercise in healthy volunteers.
2) Both drugs similarly reduced heart rate and blood pressure at rest and during exercise.
3) However, only carvedilol significantly blunted the rise in plasma noradrenaline during exercise, suggesting it has sympathoinhibitory effects that atenolol does not share.
4) This property of carvedilol may provide additional benefits for patients with heart failure over selective beta-blockers like atenolol.
Educação on-line envolve o uso da tecnologia para conectar professores e alunos que não estão fisicamente juntos, permitindo a interatividade através de ferramentas como e-mail e fóruns. Professores fornecem orientação e materiais didáticos online, enquanto alunos podem estudar e pesquisar em seu próprio tempo antes de completar atividades. Embora o acesso desigual e falta de preparação possam ser desafios, a educação on-line permite que pessoas completem graduações, mestrados e
O documento é um horário escolar para a Escola Secundária D. Inês de Castro em Alcobaça, Portugal. Ele lista os professores e as salas de aula para as aulas de História nas segundas, quartas, quintas e sextas-feiras entre 14:45-18:00 no ano letivo de 2010-2011.
Este documento descreve uma sessão de formação sobre práticas e modelos de autoavaliação de bibliotecas escolares. Os objetivos da sessão incluíram identificar instrumentos de avaliação e extrair evidências deles, formular declarações avaliativas e operacionalizar ações de melhoria. As tarefas propostas incluíram analisar instrumentos de avaliação e selecionar indicadores, escrever declarações avaliativas hipotéticas e propor uma ação de melhoria. A maioria dos participantes completou as tarefas com discussões prod
Hireko Golf Sales and Marketing WebinarHireko Golf
VP Marketing Rob Altomonte gives a sales and marketing presentation on how to make money selling Hireko Golf Clubs. View the audio portion on youtube.com/hirekogolf
O documento discute objetos de aprendizagem (OA), definindo-os como qualquer instrumento que pode ser utilizado e reutilizado para transmitir conteúdo educacional. Explica que OAs podem ser digitais ou não digitais e que sua reutilização reduz custos ao permitir compartilhamento. Também lista alguns repositórios de OAs e ferramentas como o Hot Potatoes que podem ser usadas para criar atividades digitais.
1. The patient care plan outlines criteria for discontinuing mechanical ventilation including maintaining normal ABG levels and keeping indwelling devices intact until discontinued.
2. It identifies potential nursing problems related to mechanical ventilation like alterations in cognitive function from medications or unfamiliar environment. Expected outcomes include returning to baseline mental status and understanding intubation needs.
3. Weaning procedures are described including slow, moderate, and quick methods and criteria for extubating based on assessment of respiratory effort and readiness.
This document defines and describes levels of sedation, from minimal to general anesthesia. It discusses behaviour management techniques, pharmacological and non-pharmacological approaches to sedation. Specific agents that can be used for sedation are outlined, including nitrous oxide, desflurane, sevoflurane, hydroxyzine, promethazine, diazepam, meperidine, ketamine, midazolam and propofol. Their indications, benefits, limitations and risks are provided. Guidelines for preparing for and administering sedation are also reviewed.
This document discusses the pharmacotherapy of bronchial asthma. It begins by classifying asthma and outlining its pathophysiology. It then describes various routes of drug administration, focusing on inhaled delivery methods like metered dose inhalers and nebulizers. The document details the management of asthma through both non-pharmacological and pharmacological approaches. It provides an overview of the main drug classes used to treat asthma, including beta-2 agonists, anticholinergics, methylxanthines, corticosteroids, and others. For each class, it outlines examples of drugs, their mechanisms of action, uses, dosages, and side effects.
Updates On Pharmacological Management Of Asthma In AdultsAshraf ElAdawy
The document provides information on pharmacological management of asthma in adults. It defines asthma as a chronic inflammatory airway disease characterized by airway inflammation, obstruction, and hyperresponsiveness. The diagnosis is clinical based on symptoms such as wheezing and tightness. Asthma is caused by airway inflammation and management aims to control inflammation and symptoms. Treatment involves anti-inflammatory controllers such as inhaled corticosteroids and relievers for symptoms. A stepwise treatment approach is used starting with relievers and adding preventers as needed to gain control.
RSI is a method of intubating patients who have a gag reflex who would otherwise be difficult to intubate. Intubation is accomplished by sedating and paralyzing the patient, allowing for easier intubation.
The document discusses procedural sedation, including definitions of different levels of sedation, monitoring requirements, safety considerations, common sedating agents like nitrous oxide, midazolam, fentanyl and their properties, and discharge criteria after a procedure. Procedural sedation involves administering sedatives to induce a depressed level of consciousness while maintaining cardiorespiratory function to allow medical procedures with little patient reaction or memory.
The document discusses pain pathways and effects during labor, various analgesic options for labor pain including systemic opioids, regional techniques like epidural and spinal blocks, and considerations for both maternal and fetal safety. It provides details on specific drugs and techniques, outlining advantages and disadvantages. Regional analgesia like epidural is presented as the most effective option, allowing an alert participating mother while avoiding fetal depression from systemic drugs. Factors influencing placental drug transfer and techniques for local infiltration are also summarized.
This document discusses pain management techniques for labor and delivery. It begins by outlining the pain pathways involved in each stage of labor. It then discusses the effects of pain and stress on the mother and fetus. Various analgesic techniques are discussed, including systemic opioids, nitrous oxide, local anesthetics, and regional techniques like epidural and combined spinal-epidural blocks. Risks, benefits, and considerations for both maternal and fetal safety are provided for each technique. The document concludes by emphasizing individualizing the analgesic approach based on the patient's goals and labor stage while optimizing outcomes and safety.
This document discusses guidelines for conscious sedation during periodontal and implant surgical procedures. It defines different levels of sedation from mild to moderate. Guidelines are provided for patient evaluation, monitoring, and recovery for mild and moderate sedation using oral, inhalation, or intravenous routes. Common drugs used for mild oral sedation are discussed along with dosing guidelines. Moderate sedation techniques including oral, inhalation, and intravenous administration are outlined. Safety and monitoring are important to avoid deeper levels of sedation than intended.
This document discusses conscious sedation techniques for dental procedures. It defines levels of sedation from mild to moderate. Mild sedation can be achieved through oral medications like benzodiazepines or nitrous oxide. Moderate sedation requires intravenous medications and more monitoring. The document reviews specific oral and intravenous medication options and techniques for achieving different levels of sedation. It provides clinical guidelines for patient evaluation, monitoring, and recovery when using sedation. Potential sedation failures are also discussed. The goal of sedation techniques is to reduce anxiety and discomfort during dental procedures while maintaining patient safety.
Status epilepticus is a medical emergency defined as continuous seizure activity lasting more than 5 minutes or recurrent seizures without regaining consciousness. It has an incidence rate of 10-60 per 100,000 people and is most common in children under 5 years old. Causes include infections, brain injuries, genetic conditions, and noncompliance with anti-seizure medications. The pathophysiology involves excessive excitation and reduced inhibition in the brain. Treatment involves stabilizing the patient, identifying and treating the underlying cause, giving benzodiazepines and other anti-seizure medications, and controlling refractory cases in the ICU with anesthetic medications. Early intervention is important to prevent neurological damage from prolonged seizures.
Anaesthesia and analgesia.pptx. Its nice documentfulbright2016
This document discusses pre-anesthetic preparation and medication in veterinary patients. It covers topics such as withholding food and evaluating lab work before anesthesia. It also defines different types of pre-anesthetic medications including anticholinergics, muscle relaxants, and tranquilizers. Common drugs are discussed for each category along with their indications, dosages, and side effects. Different forms of local and regional anesthesia are also introduced.
This document provides an overview of intravenous anesthetics, including their mechanisms of action, pharmacokinetics, and effects on organ systems. It discusses several specific agents such as propofol, etomidate, ketamine, benzodiazepines, thiopental. For each drug, it summarizes key points about their chemical properties, modes of action, effects, pharmacokinetics, side effects, and clinical uses. The document aims to educate medical professionals on the principles and properties of intravenous anesthetic drugs.
Controlling ICU Agitation; Context Determines Strategy Ways to Facilitate Kno...hospira2010
This document discusses managing agitation in the intensive care unit (ICU). It notes that controlling agitation is complex and context-dependent. While clinical practice guidelines aim to guide management, individualized care based on a patient's specific situation is important. Protocols need to be adapted to local practices before being adopted. The roles of various sedative agents like dexmedetomidine, benzodiazepines, and propofol are reviewed based on recent literature. Tools to facilitate applying best practices at the bedside, like order sets and clinical decision support, are recommended.
- This document summarizes guidelines from the Surviving Sepsis Campaign for the management of severe sepsis and septic shock.
- The guidelines recommend beginning resuscitation immediately for patients with hypotension or elevated lactate, obtaining cultures before antibiotics, administering broad-spectrum antibiotics within 1 hour, and controlling blood glucose with insulin.
- For patients requiring vasopressors, the guidelines suggest considering vasopressin, dobutamine, or hydrocortisone therapy and treating with recombinant human activated protein C for certain high-risk patients.
- This document summarizes guidelines from the Surviving Sepsis Campaign for the management of severe sepsis and septic shock.
- The guidelines recommend beginning resuscitation immediately for patients with hypotension or elevated lactate, obtaining cultures before antibiotics, administering broad-spectrum antibiotics within 1 hour, and controlling blood glucose with insulin.
- For patients requiring vasopressors, the guidelines suggest considering vasopressin, dobutamine, or hydrocortisone therapy and treating with recombinant human activated protein C for certain high-risk patients.
This document discusses pediatric procedural sedation and analgesia (PSA). It defines sedation as a reduction in awareness while analgesia is a reduction in pain perception. PSA involves using sedatives, analgesics, and dissociative agents to relieve anxiety and pain from medical procedures. The targeted depth of sedation and choice of agents depends on factors like the procedure, pain level, and patient characteristics. Common medication categories used include sedatives, analgesics, dissociative medications, inhalation medications, and reversal agents. Adverse events and contraindications are discussed for each category.
Summary:
Regional anesthetic techniques are increasing in popularity because of the improved recovery profiles
Intravenous adjuvants can provide patient comfort
Titrated infusion of rapid and short acting sedative drugs should enhance patient safety
Vigilant monitoring, supplemental oxygen, and the availability ressucitation equipment are strongly recommended
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Curso de introdução à informática em saúde apresentação ao colegiadoeduardo guagliardi
Este documento descreve um curso introdutório sobre informática em saúde ministrado por Renato Sabbatini na UNIPLAC em 2012. O curso será online e assíncrono, dividido em 10 módulos sobre diversos tópicos como prontuário eletrônico, telemedicina e sistemas de informação hospitalar. Os alunos serão avaliados por questionários, exercícios e discussões em fórum, podendo obter certificado se alcançarem nota mínima de 70%.
O documento discute a importância do prontuário médico para proteger médicos éticos, ameaçar aqueles sem escrúpulos, e proteger contra reclamações de pacientes insatisfeitos.
This clinical review document provides an overview of health informatics and discusses key concepts around clinical information including how it is captured, represented, interpreted, stored, and used. It examines these issues through the example of a clinical encounter between Dr. McKay and patient Ms. Smith. The document also discusses where clinical information comes from, how to assess its quality, and the various costs associated with capturing and processing information.
1. Ms Smith developed symptomatic renal impairment that may have been avoided if her underlying medical issues were properly diagnosed and treated earlier at multiple points in her care.
2. Ensuring appropriate follow-up and continuity of care between primary and secondary healthcare providers is challenging but important to reduce risks to patients.
3. The integration of clinical records and guidelines across healthcare locations and providers could help improve diagnosis, investigation, referral and follow-up to reduce risks to patients like Ms Smith.
1) Doctors must continue learning after medical school to keep up with changing knowledge, but traditional continuing education methods may not optimally impact clinical practice.
2) Workplace learning, where doctors learn by answering clinical questions that arise during patient care, is more effective for retaining knowledge and applying it.
3) However, workplace learning faces barriers like lack of time and clear questioning skills. Prioritizing urgent questions and using efficient knowledge resources can help address these barriers.
Ms. Amulya Patel uses the internet to research her risk of breast cancer after her mother's diagnosis. She finds many resources online, including patient portals and medical literature, but may have difficulty interpreting information without professional help. The document describes how electronic tools can provide initial information for health issues, but a consultation is still beneficial for personalized risk assessment and advice. Online information prompted Ms. Patel to ask her family about their cancer history, finding a strong familial link, so she sought a genetics expert's opinion. While the internet can satisfy some health questions, patients may need a doctor's expertise to properly interpret data.
This document summarizes key concepts around using clinical data and informatics tools to improve healthcare services. It discusses how data from multiple sources can be linked and analyzed to provide intelligence to decision-makers. However, issues around data protection, privacy and ensuring data is used appropriately must be addressed. Effective presentation of data is important so clinicians view it as valid and are motivated to change practices. Feedback of performance data can improve quality when done constructively and by considering the local context.
How decision support tools help define clinical problemseduardo guagliardi
1) The document discusses how decision support tools can help doctors consider issues beyond a patient's presenting problem during a consultation, including management of ongoing medical problems, opportunistic health promotion, and modifying patient help-seeking behaviors.
2) It provides an example consultation with patient Mr. Evans, who presented with headaches and sleep issues, but is also found to have high blood pressure and an alcohol problem complicating his known diabetes.
3) The document examines how electronic prompts can help bring hidden health issues to light to provide more effective treatment that addresses underlying problems driving a patient's symptoms.
This document summarizes an article about how clinical informatics tools can help make patient consultations more efficient. It discusses how computers can help clinicians obtain relevant patient information, assess the patient's status, and take effective management steps. It also explains how recording consultation data can produce useful information to improve local healthcare services and inform broader health system policies. The document provides a flow chart outlining the acute asthma management process in emergency departments for children over 5 years old.
How computers can help to share understanding with patientseduardo guagliardi
This document provides an overview of how computers and interactive health applications can help doctors share information and clinical understanding with patients. It discusses the case of Ms. Patel, who met with her doctor and genetics clinic team to discuss her family history of breast cancer and 30% lifetime risk of also developing breast cancer. The team created a genogram using software to visualize her family history and risk factors. The document then discusses the benefits of interactive tools for improving patient understanding, reducing uncertainty, and supporting patients. It also notes challenges in using these tools during medical consultations due to time constraints.
This document provides definitions for various terms related to health informatics. It defines terms such as algorithm, bioinformatics, clinical coding system, clinical data system, clinical decision tool, communication, database, electronic health record, and medical knowledge. The definitions cover topics such as the use of informatics methods and technologies in clinical care, research, public health, and consumer health contexts.
1) The document discusses the promise and potential perils of eHealth technologies like remote monitoring devices, virtual assistants, and personalized health records.
2) Factors driving eHealth include patient demand for convenient access to information, the ability to link separate health services, and using technology to address staffing shortages. However, eHealth may also shift costs to patients and change the role of healthcare providers.
3) Potential benefits of eHealth include improved patient information and choice, better communication between providers, and links to vetted external health resources. However, ensuring privacy and appropriate access to personal health data is also discussed.
Directory information is vital for navigating healthcare services but is often inadequate. It provides contact details of local services, specialists' preferences, and how to access tests and referrals. However, directory information is difficult to maintain as it is locally specific and changes frequently. While new technologies may help, current solutions are fragmented without a consistent format or centralized responsibility. Improving the collection and use of accurate, up-to-date directory information could support clinicians and reduce patient frustrations when navigating the healthcare system.
This document summarizes key aspects of clinical review and use of health informatics in patient assessment. It discusses 1) using open questions rather than closed questions to understand the patient's reason for visiting, 2) considering symptoms and non-verbal cues to form an initial hypothesis, 3) gathering a medical history over time to understand recurring issues, 4) reviewing records such as laboratory results, prescriptions, and family history to inform the diagnosis, and 5) the importance of coding clinical data for storage and communication between healthcare providers and systems.
Este documento discute o prontuário eletrônico do paciente (PEP) na assistência, informação e conhecimento médico. Ele apresenta o PEP e sua importância, discute padrões de registro e transmissão de dados em saúde, e examina aplicações do PEP em diversas áreas como educação, pesquisa, telemedicina e gestão da qualidade. O documento é direcionado a profissionais de saúde e tem como objetivo difundir os conceitos e benefícios do PEP.
O documento discute as diferenças entre depressão unipolar e bipolar, enfatizando que: 1) a depressão é frequentemente a apresentação inicial do transtorno bipolar, mas é erroneamente diagnosticada como unipolar; 2) os bipolares passam mais tempo deprimidos do que maníacos/hipomaníacos; 3) vários sintomas e características sugerem um diagnóstico de bipolaridade ao invés de unipolar.
O documento discute a importância da informática na saúde e propõe várias iniciativas de colaboração entre a Sociedade Brasileira de Informática em Saúde (SBIS) e a Uniplac, incluindo cursos online sobre o tema para alunos e professores e a exibição de webconferências gravadas.
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
1. Clinical review
ABC of health informatics
How computers help make efficient use of consultations
Frank Sullivan, Jeremy C Wyatt
Efficient consultations deal with patients’ problems promptly
This is the seventh in a series of 12 articles
and effectively while taking into account other relevant
A glossary of terms is available at http://bmj.com/cgi/
circumstances. Sometimes the relevant circumstance is another content/full/331/7516/566/DC1
health problem in the patient or their family, or it could be an
issue affecting society at large, such as resource constraints. The
immediate role of the team caring for Patrick Murphy (see box
opposite) is to deal with his severe asthma. Patrick Murphy is a 5 year old boy who has been
To do so the team needs information on the current brought to the accident and emergency department with
problem, which is quickly obtained from Patrick’s mother (who status asthmaticus. He is cyanosed with a poor respiratory
accompanied him in the ambulance) and background details effort
from her or from his medical records. They also need to assess
Patrick’s physical status using clinical examination and other
diagnostic methods. The information obtained enables the
clinicians caring for Patrick to take the most effective Assess asthma severity
management steps. In the longer term, data from the
Moderate exacerbation Severe exacerbation Life threatening asthma
consultation may be used to redesign the service locally, or at • SpO2 ≥92% • SpO2 <92% • SpO2 <92%
• Peak expiratory flow ≥50% best or • Peak expiratory flow <50% best or • Peak expiratory flow <33% best or
the level of the health system. This article shows how predicted predicted predicted
• No clinical features of severe asthma • Heart rate >120/min • Silent chest
informatics tools can make it easier to record important data, NB: If a patient has signs and • Respiratory rate >30/min • Poor respiratory effort
symptoms across categories, always • Use of accessory neck muscles • Altered consciousness
and that this processing can produce useful information for a treat according to their most severe • Cyanosis
features
low cost.
• Give nebulised β2 agonist:
Most doctors focus on assessing the patient and carrying • β2 agonist 2-10 puffs via spacer salbutamol 2.5 mg or terbutaline 5 mg with oxygen as
• Reassess after 15 minutes driving gas
out immediate management steps. Some clinicians see the • Continue O2 via face mask/nasal prongs
• Give soluble prednisolone 30-40 mg
recording of what happened and why as a necessary evil to be or intravenous hydrocortisone 100 mg
done in the minimum time, with the least effort. Legal
Responding Not responding If life threatening features present
responsibilities ensure that most encounters are recorded, but • Continue inhaled β2 agonist 1-4
hourly
• Repeat inhaled β2 agonist
• Add 30-40 mg soluble oral
Discuss with senior clinician, paediatric
intensive care unit team, or paediatrician
the quality of data is often constrained, partly because so much • Add 30-40 mg soluble oral
prednisolone
prednisolone
Arrange admission
Consider:
• Chest x ray and blood gases
data are required. (lower threshold if concern over social
circumstances)
• Bolus intravenous salbutamol
15 µg/kg of 200 µg/ml solution over
10 minutes
• Repeat nebulised β2 agonist
Plus:
Discharge plan • Ipratropium bromide 0.25 mg
Data to be recorded for acute medical admissions • Continue β2 agonist 4 hourly nebulised
• Consider prednisolone 30-40 mg daily for up to 3 days
x Patient’s registered general practice details • Advise to contact GP if not controlled on above treatment
• Provide a written asthma action plan Arrange immediate transfer to paediatric intensive care unit/
x Admission details (administrative) • Review regular treatment high dependency unit if poor response to treatment
• Check inhaler technique Admit all cases if features of severe exacerbation persist after
x Reason for clinical encounter • Arrange GP follow-up initial treatment
x Presenting problem
x History of presenting problem Acute asthma management flow chart for children >5 years in accident and
x Current diagnoses, problems emergency department. Adapted from Scottish Intercollegiate Guidelines
x Drugs, allergies, and diets Network, guideline 63 (www.sign.ac.uk/guidelines/fulltext/63/index.html)
x Past illnesses, procedures, and investigations
x Social circumstances
x Functional state
x Family history
Clinical data
x Systems review Results of care-based and cohort audit
x Examination results Health needs assessment
x Results of investigations External data (eg national comparators)
x Overall assessment and problem list Information
x Management plan Evidence including research
x Intended outcomes Guidelines
x Information given to patient and carers Experience
External comparison
Textbooks
Knowledge
Protocols
Write once, read many Formularies
Reminders
Other tasks in the emergency consultation include gathering Feedback on performance
Commissioning
and recording information that may be useful to Patrick or
Change
other patients in the future. Paper or electronic records, or
Clinical effectiveness
other information tools, may make it easier to record items of Cost effectiveness
data that can be aggregated and analysed after the event. The Clinical governance
Outcomes audit
data can improve efficiency when they are entered into clinical
Improved outcomes
records and made available to other members of the clinical
team. Wireless networks allow data to be transmitted to and
from handheld computers, laptops, or desktop computers. This Turning clinical data into improved patient outcomes
1010 BMJ VOLUME 331 29 OCTOBER 2005 bmj.com
2. Clinical review
enables data to be shared early. An improved standard of record
keeping probably means better data in the electronic patient
record, which increases knowledge about the range of problems
seen in clinical practice. This new knowledge informs decisions
made at several levels, and contributes to better outcomes for Classification, coding, and nomenclature
patients. x Classification is a method for systematically grouping
something—for example, diseases. In most classifications, classes are
designated by codes, which allow aspects of the things to be
captured (a systematic arrangement of similar entities on the basis
Structured recording of data of certain characteristics)
x A code is usually a unique numeric or alphabetic representation of
Although modern computers have massive processing and
items in a classification
storage capacity, data needs to be recorded in code to be x Nomenclature is a system of naming used in a branch of
“understood” by computers. The computer processes and knowledge. Medical nomenclature attempts to standardise the
analyses the data to add meaning. Free text notes are too names used for patient findings, diseases, interventions, and
difficult for computers to process so that clinicians and outcomes
policymakers can carry out analyses on them.
Although there are many coding and classification systems,
according to Gardner, one system aims to “create a new world
standard for computerising medical terminology.” It is called the
Secondary uses of data captured during consultations
systematised nomenclature of medicine and clinical terms
(SNOMED-CT) system. This coding system will be used in the x Reminders and decision support
x Communication of clinical data between healthcare workers—for
NHS. It is a detailed, coded classification of medical terms and
example, discharge summaries, referrals, ordering, and requests
concepts, and has more than 150 000 terms and codes that are x Identifying and monitoring the health needs of a population
organised into 11 linked, hierarchical modules. Doctors will not x Reducing bureaucracy while managing and funding care delivery
see, and do not have to remember, all these codes. They use the x Enabling reporting of externally specified health statistics—for
interface provided by their clinical system, which is intuitive and example, for infection control
carries out all the necessary translation to and from English. x Effective and efficient resource allocation and healthcare
To realise all potential efficiencies, the electronic record management
x Research
must comply with several requirements. The variables to be
x Education
collected and their format may be agreed at different levels: x Local clinical audit and governance
hospital, region, organisation, or country. The electronic records
should also be shared appropriately among different
organisational units using standard communications
procedures, and they must be subject to security and
Lateral view Medial view
confidentiality protocols. Computer systems designed with
sharing in mind are called “open.” They can run programs that A Posterior Malleolar zone B Posterior
edge or tip edge or tip
connect with systems of the same type, and can accept of lateral Midfoot zone of medial
programs or connections from other sources. malleolus 6 cm 6 cm malleolus
D Navicular
C Base
Rapid decisions and the human brain of 5th
metatarsal
In Patrick Murphy’s case, effective use of consultation data may
An ankle x ray series is required only if A foot x ray series is required only if
not require a computer. Most clinical decision making is done there is any pain in malleolar zone and there is any pain in midfoot zone and
faster than current computer technologies can manage. any of these findings: any of these findings:
• Bone tenderness at A • Bone tenderness at C
• Bone tenderness at B • Bone tenderness at D
• Inability to bear weight both • Inability to bear weight both
Clinical prediction rules immediately and in emergency
department
immediately and in emergency
department
A clinical prediction rule, sometimes called a clinical decision
rule, is a method that quantifies the individual contributions Ottawa ankle rules for use of radiography in acute ankle injuries. Adapted
made by various components of the history, examination, and from Stiell IG, et al. JAMA 1994;271:827-32
basic laboratory results towards the diagnosis, prognosis, or
likely response to treatment in a specific patient. Clinical
prediction rules increase the accuracy of clinicians’ diagnostic
and prognostic assessments. They have been developed to help Factors predicting a future risk of developing near-fatal or
diagnose and manage patients with a wide range of diseases fatal asthma
and in different settings. They reduce the uncertainty inherent
x Socioeconomic deprivation
in medical practice by defining how to use clinical findings to x Previous near fatal asthma—for example, previous ventilation or
make predictions. respiratory acidosis
Every rule should assist the doctor in making a decision, and x Previous admission for asthma, especially if in past year
each one is based on factors drawn from a patient’s history, x Requiring three or more classes of asthma medication
physical examination, or diagnostic tests. The Ottawa ankle rule x Overuse of ß2 agonist
x Repeated attendance at accident and emergency department for
is often used. The Ottawa Health Research Institute keeps an
asthma care, especially if in past year
inventory of clinical prediction rules. In August 2004 it x Brittle asthma
recorded 523 prediction rules, 337 of which were validated x Poor adherence to drug regimen
using Cochrane methods.
BMJ VOLUME 331 29 OCTOBER 2005 bmj.com 1011
3. Clinical review
After decisions about how to manage a clinical problem
have been made, admissions that are potentially avoidable Continuity of care*
should be considered. Using data to stratify the risk of For patients and their families the experience of continuity is the
recurrence may enable doctors to vary the level of follow-up perception that providers know what has happened before, that
and to tailor treatment depending on the risk—for example, the different providers agree on a management plan, and that a provider
who knows them will care for them in the future. For providers, the
risk of Patrick’s asthma recurring.
experience of continuity relates to their perception that they have
sufficient knowledge and information about a patient to best apply
their professional competence, and they have the confidence that
Establishing trust their care inputs will be recognised and pursued by other providers.
An effective consultation instils trust and develops the *From Haggerty JL, Reid RJ, Freeman, GK, Starfield BH, Adair, CE, McKendry
relationship between doctor and patient. In Patrick’s case, his R. Continuity of care: a multidisciplinary review. BMJ 2003;327:1219-21
family will probably consider returning to the team who dealt
with his problems on this occasion for further care. When a
patient sees the same doctor over time in a general practice
surgery or outpatient clinic, it makes the consultation more
Useful material on websites
efficient for both parties. The patient’s story need not be
repeated, and clinical examinations provide data that are x To read about the information strategy of the UK NHS see
comparable. When personal continuity of care is not possible, www.nhsia.nhs.uk/def/pages/info4health/contents.asp
x Background reading and justification on proposed record keeping
the electronic patient record provides some organisational standards can be found at http://hiu.rcplondon.ac.uk/
continuity. Complete and accurate recording of data by clinicalstandards/recordsstandards/index.asp
clinicians becomes more important when a different member of x The Ottawa Health Research Institute inventory of validated
the healthcare team needs to know what information is already decision rules can be accessed at www.ohri.ca/programs/
known, or deduced, about the patient. clinical_epidemiology/OHDEC/clinical.asp
Efficient use of consultation time
The time available during consultations is often constrained,
and doctors may need to select the most important problems to Further reading
deal with. In a case like Patrick’s, this is simple: the severity of his x Berwick DM. A primer on leading the improvement of systems.
physical disease means that his acute respiratory problem must BMJ 1996;312:619-22
be managed. On a later occasion (for example, at the next x Gardner M. Why clinical information standards matter. BMJ
2003;326:1101-2
outpatient visit) discussing parental smoking or pets in the
x Wasson JH, Sox HC. Clinical prediction rules: have they come of
house may be the best use of time. Looking over the patient’s age? JAMA 1996;275:641-2
records before a consultation may alert the doctor to x Wyatt JC, Altman DG. Prognostic models: clinically useful, or
opportunities for efficient use of time. Patients often forget quickly forgotten? BMJ 1995;311:1539-41
much of what is said during a consultation, and giving them an x Schatz M, Cook EF, Joshua A, Petitti D. Risk factors for asthma
audio recording of consultations is an easy and cheap way for hospitalizations in a managed care organization: development of
a clinical prediction rule. Am J Manag Care 2003;9:538-47
patients to listen to the advice provided after their visit is
x Guthrie B, Wyke S. Does continuity in general practice really
over. Providing patients with a written leaflet or advice about matter? BMJ 2000;321:734-6
a self help organisation with materials on its website is also x Bates DW, Kuperman GJ, Wang S, Gandhi T, Kittler A, Volk L, et al.
useful. Ten commandments for effective clinical decision support: making
the practice of evidence-based medicine a reality. J Am Med Inform
Assoc 2003;10:523-30
Summary
The strengths of human thought processes may be
complemented by the strengths of electronic tools. The initial
costs of developing and implementing new information systems Frank Sullivan is NHS Tayside professor of research and development
may be high, but the costs thereafter can be lower than the in general practice and primary care, and Jeremy C Wyatt is professor
non-electronic source that is being replaced. In 2003, American of health informatics, University of Dundee.
policymakers said that $120 billion a year could be saved by The series will be published as a book by Blackwell Publishing in
using information systems. Well designed, new, informatics tools spring 2006.
typically improve effectiveness by 10-15%. Lower costs and Competing interests: None declared.
better outcomes mean that informatics tools are moving from
an era of hype to one in which real benefits are seen. BMJ 2005;331:1010–2
1012 BMJ VOLUME 331 29 OCTOBER 2005 bmj.com