A presentation given by Rachael Worthington at the 2012 CHA Conference, The Journey, in the 'Innovations in Supporting Acutely Unwell Children, Young People & Their Families' stream.
A presentation by Melissa Fox at the CHA Conference 2012, The Journey, in the 'Innovations in Supporting Acutely Unwell Children, Young People & Their Families' stream.
A presentation given by Gabrielle Murphy at The Journey, CHA Conference 2012, in the 'Innovations in Mental Health Care for Children and Young People' stream.
A presentation by Melissa Fox at the CHA Conference 2012, The Journey, in the 'Innovations in Supporting Acutely Unwell Children, Young People & Their Families' stream.
A presentation given by Gabrielle Murphy at The Journey, CHA Conference 2012, in the 'Innovations in Mental Health Care for Children and Young People' stream.
A presentation given by Elizabeth Harnett at the CHA Conference 2012, The Journey, in the 'Delivering Safety & Quality: Innovations in Clinical Governance' stream.
A presentation given by David Fitzsimons in the 'Delivering Safety & Quality: The Health Reform Agenda stream at the CHA Conference 2012, The Journey, in October.
A presentation given by margaret Allwood at teh 2012 CHA Conference, The journey, in the 'Innovations in Supporting Acutely Unwell Children, Young People & Their Families' stream.
A presentation given by Sharon Payne at the 2012 CHA Conference, The Journey, in the 'Innovation in Supporting Acutely Unwell Children, Young People and Their Fmailies' stream.
Presented by Mr David Fitzsimons, Clinical Specialist Speech Pathologist from the Children's Hospital at Westmead, at the CHA Conference on 24 October 2012
A presentation given by Nick Kowalenko at The Journey, CHA Conference 2012, in the 'Innovations in Mental Health Care for Children and Young People' stream.
A presentation given by Sonya Preston at The Journey, CHA Conference 2012, in the 'Delivering Safety & Quality: Innovations in Clinical Governance' stream.
A presentation given by Sue Peter at the 2012 CHA Conference, The Journey, in the 'Delivering Safety & Quality: Innovations in Clinical Governance' stream
Most current highly active antiretroviral therapy (HAART) regimens for HIV-positive patients contain two nucleoside reverse transcriptase inhibitors (NRTIs) with either a Protease inhibitor (PIs) or a non-nucleoside reverse transcriptase inhibitors (NNRTI). Notwithstanding the regulatory guidelines recommending therapeutic drug monitoring (TDM) for these drugs, therapeutic failure is a very serious concern implying drug induced toxicity and more importantly viral rebound and viral resistance.
Single dose, steady state and dose ranging studies have all more or less demonstrated that there is a positive correlation between plasma concentrations and therapeutic effects of anti-retrovirals (ARVs). However, one of the main challenges still seems to be the target concentrations for these drugs and their relevant inhibitory quotient. In this talk, we are going to examine these issues along with bioanalytical challenges, drug-effect and drug –toxicity relationships and finally drug-drug interactions within different HAART regimes.
Audit of Inclusion Health in the Emergency Department.
Audit of the emergency care for the homeless population at City and Sandwell Hospitals, Birmingham.
A presentation given by Elizabeth Harnett at the CHA Conference 2012, The Journey, in the 'Delivering Safety & Quality: Innovations in Clinical Governance' stream.
A presentation given by David Fitzsimons in the 'Delivering Safety & Quality: The Health Reform Agenda stream at the CHA Conference 2012, The Journey, in October.
A presentation given by margaret Allwood at teh 2012 CHA Conference, The journey, in the 'Innovations in Supporting Acutely Unwell Children, Young People & Their Families' stream.
A presentation given by Sharon Payne at the 2012 CHA Conference, The Journey, in the 'Innovation in Supporting Acutely Unwell Children, Young People and Their Fmailies' stream.
Presented by Mr David Fitzsimons, Clinical Specialist Speech Pathologist from the Children's Hospital at Westmead, at the CHA Conference on 24 October 2012
A presentation given by Nick Kowalenko at The Journey, CHA Conference 2012, in the 'Innovations in Mental Health Care for Children and Young People' stream.
A presentation given by Sonya Preston at The Journey, CHA Conference 2012, in the 'Delivering Safety & Quality: Innovations in Clinical Governance' stream.
A presentation given by Sue Peter at the 2012 CHA Conference, The Journey, in the 'Delivering Safety & Quality: Innovations in Clinical Governance' stream
Most current highly active antiretroviral therapy (HAART) regimens for HIV-positive patients contain two nucleoside reverse transcriptase inhibitors (NRTIs) with either a Protease inhibitor (PIs) or a non-nucleoside reverse transcriptase inhibitors (NNRTI). Notwithstanding the regulatory guidelines recommending therapeutic drug monitoring (TDM) for these drugs, therapeutic failure is a very serious concern implying drug induced toxicity and more importantly viral rebound and viral resistance.
Single dose, steady state and dose ranging studies have all more or less demonstrated that there is a positive correlation between plasma concentrations and therapeutic effects of anti-retrovirals (ARVs). However, one of the main challenges still seems to be the target concentrations for these drugs and their relevant inhibitory quotient. In this talk, we are going to examine these issues along with bioanalytical challenges, drug-effect and drug –toxicity relationships and finally drug-drug interactions within different HAART regimes.
Audit of Inclusion Health in the Emergency Department.
Audit of the emergency care for the homeless population at City and Sandwell Hospitals, Birmingham.
HIV screening and treatment in as changes occur in our healthcare system. Targeted towards specific healthcare centers in Baltimore. Features some data from the Department of health and mental hygiene and new data on HIV transmission across continuum of HIV care.
Anaemia in ICU patient. Vampirism in critical care. Unnecessary bloodletting draws. Iatrogenic anaemia. Secondary anaemia. Do not do recommendations to avoid unnecessary analytics
A presentation given by Prof. Phil Robinson at The Journey, CHA Conference 2012, in the 'Innovations in Mental Health Care for Children and Young People' stream.
A presentation given by Jacques Esterhuizen at The Journey, CHA Conference 2012, in the 'Innovations in mental Health Care for Children & Young People'
A presentation given by Susan Jury & Andrew Kornberg at The Journey, CHA Conference 2012, in the 'Enhancing Outcomes Through Innovations in Technologies' stream.
A presentation given by Cheryl McCullough at The Journey, CHA conference for 2012, in the 'Enhancing Outcomes Through Innovations in Technologies' stream.
A presentation given by Leanne Crittenden & Cathy Hastings at the October 2012 CHA Conference, The Journey, in the 'Service Redesign & Innovation' stream.
A presentation given by Joyce Murphy and consumers at the October 2012 CHA Conference, The Journey, in the 'Innovations in Supporting Chronically Unwell Children, Young People and Their Families' stream.
A presentation given by Prof. David Croaker & Eunice Gribben at the CHA Cofnerence in October 2012, The Journey, in the 'innovations in supporting chronically unwell children, young people and their families' stream.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Rachael Worthington - A Point Prevalence Study of Paediatric IV Fluids
1. A Little more salt with that
order?
IV Fluids in Paediatrics
Rachael Worthington
The Children’s Hospital at Westmead
2. Background
• The danger of intravenous hypotonic saline administration,
to acutely ill or post-operative children has been well
documented over the past decade.
• Children’s Hospitals Australasia (CHA) Medication safety SIG
Intravenous Fluids Working Party, in line with other safety
organisations, released intravenous fluid guidelines which
addresses this.
• Local intravenous fluid types for use in children and
adolescents across a range of settings, including
maintenance fluids, the perioperative period, dehydration
and resuscitation, were reviewed.
Moritz ML and Ayuz JC Pediatr nephrol 2005
Armon et al Arch Dis Child 2008
3. Questions raised
• Is there really harm from
hypotonic saline?
• Is maintenance fluid Na+
volume too much?
• How should we be
monitoring?
• Sodium Chloride 0.45%
vs 0.9% vs balanced salt
solution
Hatherill Arch Dis Child 2004
Coulthard MG Arch Dis child 2008
4. Local incident data - 2011
• Graph showing IV fluids up there over last 4
years
6. CHW Incident data
IV Fluid Prescribing Incidents 2011
N=25
4% 8%
IV Fluid Administration Incidents 2011
Documentation
Not prescribed N=91
28% Policy and procedure
Unclear/ambiguous
48%
Wrong IV fluids Extravasation
14%
8% Wrong patient ID No order
4%
Ceased incorrectly
38% Expired stock
13% IV incompatibility
Line issues
Omission
Policy and procedure
11%
Wrong order administered
Wrong IV Fluids
1%
12% Wrong rate
4% 3%
2% 1%
1%
11. Method: Audits
• IV fluid data was collected, from current fluid order charts, patient notes, and the
clinical documentation system (PowerchartTM) on a single day in February 2010
(pre-change) and in October 2012 (post change) from every hospital ward, with
the exception of the Neonatal Nursery.
• Data collected included demographic patient data (diagnosis, co-morbidities and
factors associated with non osmotic ADH secretion), IV fluids, additives and rate
prescribed, fluid balance and serum electrolytes.
• The quality of prescribing of IV fluids was also documented.
• Data was analysed for type of fluid used (maintenance and bolus), appropriateness
(met patient requirements), presence of hypo or hypernatraemia (and any action
taken) and quality of prescribing.
• Hyponatraemia was defined as mild (Sodium <135mmol/L) or moderate/severe
(Sodium <130mmol/L)
• Hypernatraemia was defined as mild (Sodium > 145mmol/L) and moderate/severe
(Sodium >150mmol/L)
12. Demographics
Mean (Range) Audit 1 n=95 Audit 2 n=104
Age 6.54 (9 days-18 years) 6.44 (7 days-18 years)
Male 58 58
Weight (Kg) 25.75 (3.5-69.8) 23.53 (2.83-87)
Medical/surgical 59/36 53/51
Duration of IV Fluids (dys) 8.92 (<1 – 70) 10.3 (<1-80)
Sodium Range (mmol/L) 127-144 121-154
Number fluid boluses 37 29
14. Audit 1 and 2 results compared
Audit 1 n=98 Audit 2 N=104
Fluids met requirements 100% 100%
Hypernatraemia? 0% 1%
Hyponatraemia? 32% 34%
Sodium Chloride 0.225% 0% 0%
prescribed
Sodium Chloride 0.9% 97% 100%
used as bolus fluid (crys)
Daily weights as per 38% 35%
protocol?
Electrolytes monitored 27% 32%
as per protocol?
Quality of prescribing: No-84% No-90%
orders clear/complete?
15. Discussion
• No change in hyponatraemia or hypernatraemia
observed – but fluid types used only marginally
changed.
• Use of sodium chloride 0.9% plus 5% glucose as
maintenance is slowly increasing (PICU).
• Documentation needs to be tightened across the
board.
• Regular cycle of audit.
• Educational input to date (JMO lunches, PrInt
students, undergraduates, nursing orientation) –
enough?
16. Multi faceted approach
over 4 years
• Clinician engagement
• Multi D communication
• Interactive education
• Timely feedback
17. In summary
• IV fluids still feature in the top 5 Medication/IV fluid
incident reports every month.
• Statewide NSW paediatric IV fluid guidelines have been
developed based on CHA recommendations.
• Maintaining/sustaining policy into practice – ‘active’
implementation, ongoing education, ‘living’ policy with
timely review, safety culture, audit and
feedback, changing educational strategy.
• Change to sodium chloride 0.9% or balanced salt
solution in the near future
• One size does not fit all.
aAtleast 50 case reports of serious morbidity including at least 27 deaths amongst children who developed hospital acquired hyponatraemia whilst receiving iV fluids (Moritz ML, Ayuz JC. Pediatrnephrol 2005;20:1687-1700Add in image of patient safety alert 22 from NPSAArmon et al paper of audit Arch Dis child 2008 – point prevalence in 17 hospitals (10 DGHs, 3 patients each; 7 university teaching hospitals, 7 patients each, total 99 patients reviewed). Reviewed… in 2 audits, one prior to and the other after change in practice
Screen shots of these papers….Normal sodium requirement in children – orally 20-27mmol/L (similar to 30mmol/L in N/5) – see paper by MG Coulthard Arch Dis Child 2008, which describes why and has an algorithmGlobal concern about type of fluids and methods of prescribing Rubbing salt in the wound – M Hatherill – Traditional reccommendations for maintenance fluid volume exceed actual requirements and may contribute to the development of hyponatraemiaM Coulthard audit published in January 2012 – prospective, randomised open label study. 82 children, hartmanns and 5% dex or 0.45% saline and 5% dex.RBH PICU post spinal instrumentation, craniotomy or cranioplasty surgery – 7 patients in 0.45% group hyponatraemic 16-18 h post-op, cf none in hartmanns group Not fluid restrictive, saltier solution admin safer and more practical approach – urinary sodium same in both groups Neville papers – fluid type rather than rate determines post-op risk for hyponatraemiaRef 24 – Yung – greater fall in sodium with N/5/dexcf NS/dex, and that fluid admin at full maintenance greater fall than restricted rate.
Add in graph to show Iv fluids number one, but nature of these incidents is around administration (line/pump issues, wrong rate/fluid based on what prescribed/used outside policy/extravasation injuries etc) – administration without consideration of ideal fluid type
Add in IV fluid image and IV fluid management policy screen shotA working party was convened to implement the new fluid guidelines into practice. The data was used to inform the development of a new IV fluid order chart, local guidelines and educative strategies used.
On a single day in 2010 (pre-change) and again in 2012 (post change – incident numbers rising)
Demographic table for pre and postAgeTeam underDiagnoses – neuro/gastroCo-morbidsDuration IV fluidsType (graph)% requirements (dehydinc if documented)Electrolytes in preceding 24 hours? (P and ur)Na levelsdocumentation
Combine this with slide above
104 out of 215 patients were receiving IV fluids100% of the patients received IV fluid volumes calculated in accordance with the new guidelines, and titrated to oral intake and output. 34% had mild hyponatraemia documented as their sodium level on the day of or within a week of the audit.Complex patients in post audit: One patient with DI had sodium levels between 145-154mmol/L managed with desmopressin and fluids were appropriate. Compliance with monitoring electrolytes increased, but weights decreased in patients receiving >48 hours IV fluids as per protocol – new protocol allows for more clinical judgement after the first 24 hours – explore this further. The orders themselves were incomplete and the prescriber unclear in 90%. Quality of prescribing – real estate tight on form, all should be completed, guidance on backWhat was missing – calculation in the main, prescriber clarity, weight, abbreviations used for sodium choride and strengths and glucose as dex or D
Hyponatraemia is observational – audit did not allow for detailed evaluation of clinical status and parameters for each patientN/4 not used pre-change in fluids – may need more than N/2 – guidelines expected to change in next iterationPatients tx fromED/PICU – not transcribed to ward charts (similarly from theatres)Rates not matching what is prescribed – sometimes documented in progress notes but not on fluid orderFluid balance chart difficult to interpretAudit – small, regular, as part of daily ward rounds (aka Lester) or via EOC – audit app in development to make this easySimulation exercises for practical application of IV fluid management – all disciplines (inc pharmacists) -
For sustainability in reducing adverse drug events or maintaining the quality of what we do …important to use a multifaceted approach
IV fluids in Top 5 incidents each month – mix of administration and prescribing – continued vigilance.Statewide guidance – 500ml bags and neonatal guidance included.Policy into practice changes and sustaining – Hurdowar et al paper from Healthc Q 2009. Canada. ‘Active’ ImplementationHow do we educate – enough, more hands on, prescribing expectations clear?Change of fluids again – awaiting results of trial at RCH melbourne comparing standard to BSS – recruitment slow but ongoingOne size does not fit all – care with population unable to adapt to low sodium fluids.