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Biomedical subjects

P G Nightingale

Publications and source records attributed to P G Nightingale.

14 recordsLinked to original sources
PubMed2000

Implementation of rules based computerised bedside prescribing and administration: intervention study.

OBJECTIVES: To implement and assess a rules based computerised prescribing system with the aim of improving the safety of prescriptions and the administration of drugs. DESIGN: Analysis of performance of computerised system plus questionnaire survey of users. SETTING: 64 bed renal unit in a teaching hospital. INTERVENTION: : Introduction of the system into routine clinical use. MAIN OUTCOME MEASURES: Number of attempted prescriptions cancelled by the system; proportion of warning messages overridden; users' comparisons of the system with conventional procedures. RESULTS: Between October 1998 and August 1999 the system cancelled 58 (0.07%) out of 87 789 prescriptions on the grounds of clinical safety. In addition, 427 (57%) attempted prescriptions generating high level warnings and 1257 (8%) generating low level warnings were not completed. In a user survey 82% (31/38) of doctors and nurses considered the system to be an improvement on conventional procedures. CONCLUSIONS: The system has contributed to safety and patient care. All prescriptions are complete and legible, and transcription errors have been eliminated. The system assists clinicians when they are writing a prescription by making available information on patients. The system supports clinical decision making and has been well received by doctors, nurses, and pharmacists.

Drug Therapy, Computer-Assisted↗
PubMed2000

Blood transfusion requirements in femoral neck fracture.

The blood transfusion requirements of a consecutive series of 249 unselected patients with femoral neck fracture were studied retrospectively. A total of 339 Units of blood were transfused (a mean of 1.36 Units per patient). Blood transfusion occurred in 132 patients (53.0%), with each receiving a mean of 2.57 Units. Patients aged 80 years and above as a group were transfused significantly more blood than those aged less than 80 years: 1.64 vs 0.94 Units, X2 = 12.09, p < 0.001. Patients with intertrochanteric fractures were transfused significantly more blood than those with intracapsular fractures (1.74 vs 1.00 Units: X2 = 13.4, p < 0.001).

Age Factors↗
PubMed1999

Cognitive assessment in elderly patients admitted to hospital: the relationship between the Abbreviated Mental Test and the Mini-Mental State Examination.

OBJECTIVE: To determine the relationship between Abbreviated Mental Test (AMT) and the Mini-Mental State Examination (MMSE) in elderly patients admitted to hospital. DESIGN: Prospective study of 364 consecutive admissions to an elderly medicine unit. Eighty-eight (24.2%) patients were excluded. The AMT and MMSE were administered to the remaining 276 patients and the relationship between the two tests evaluated statistically. SETTING: Inner city teaching hospital. SUBJECTS: Two hundred and seventy-six patients admitted to the elderly medicine unit during October and November 1997. MAIN OUTCOME MEASURES: Predictive efficiency of the AMT for cognitive state by MMSE (the percentage of patients whose cognitive state by the MMSE was correctly categorized by the AMT). Association and predictive relationship between individual AMT and MMSE scores. RESULTS: There was a significant relationship between cognitive state as determined by the AMT and MMSE: chi2 = 101.3, df = 1, p <0.001. The predictive efficiency of the AMT was 79.0% (218/276). A strong association was found between the AMT and MMSE (Somers' d statistic 0.75: p <0.001). Simple linear regression allowed prediction of the MMSE score from the AMT score as follows: MMSE score = 7.06 + (1.94 x AMT score); p <0.001. CONCLUSIONS: In patients admitted to the elderly medicine unit, the AMT gave predictive information about cognitive status as determined by the MMSE, and also a prediction of likely MMSE score.

Aged↗
PubMed1998

Chronic renal failure following liver transplantation: a retrospective analysis.

BACKGROUND: Liver transplant recipients are at risk of chronic renal disease, principally as a result of nephrotoxicity of the commonly used immunosuppressive agents cyclosporine and tacrolimus. We have investigated the incidence of chronic renal failure and its risk factors in our transplant population, which was treated predominantly with cyclosporine. METHODS: A single-center retrospective study was done of 883 consecutive adult patients receiving a first liver transplant between 1982 and 1996. Potential risk factors for the development of chronic renal failure were recorded, including serial measurements of cyclosporine therapy and renal function. RESULTS: Severe chronic renal failure (serum creatinine level >250 microM/L for at least 6 months) developed in 25 patients, representing 4% of patients surviving 1 year or more. Twelve of these patients developed end-stage renal failure and mortality was 44%. The predominant cause of renal failure was cyclosporine nephrotoxicity. Serum creatinine as early as 3 months after surgery was strongly associated with the eventual development of severe chronic renal failure (P=0.001), and this group could be further subdivided into two groups with differing risk factors. The first group had early (<1 year) renal dysfunction, with older age (P=0.03), cytomegalovirus infection (P=0.03), need for perioperative renal replacement therapy (P=0.06), and regrafting (P=0.06) as risk factors for eventual renal failure; the second group had late-onset (>1 year) renal dysfunction, with cyclosporine levels at 1 month after surgery (P=0.007) and daily and cumulative cyclosporine dosage at 5 years (P=0.01 for both) as risk factors. CONCLUSIONS: With improved survival of liver transplant recipients, chronic renal failure has become an important cause of morbidity and is associated with a high mortality. Many patients at risk of severe chronic renal failure may be identified at an early stage. Treatment regimens that avoid or prevent cyclosporine-induced nephrotoxicity are urgently required for this population.

Adolescent↗
PubMed1997

Evaluation of a shortened version of the Abbreviated Mental Test in a series of elderly patients.

OBJECTIVE: To determine whether a shortened version of the Abbreviated Mental Test is as effective as the Abbreviated Mental Test (AMT) itself in assessing cognition in elderly patients. DESIGN: A shortened four-item version of the Abbreviated Mental Test (AMT4) was constructed using the following items: (1) Age, (2) Date of birth, (3) Place, and (4) Year, with impaired cognition indicated by an AMT4 score of less than four. Patients were assessed with the AMT. The AMT4 scores were then determined and matched against AMT scores. The performance of all 210 possible four-item combinations derivable from the AMT was assessed and ranked according to predictive efficiency (the percentage of patients whose cognition as judged by the AMT was correctly categorized by each four-item combination). SETTING: Inner-city teaching hospital. SUBJECT: Two hundred consecutive elderly patients seen on domiciliary visits, in the clinic or as orthogeriatric referrals. RESULTS: The AMT4 score showed a statistically significant correlation with AMT score (Somers' d statistic 0.90: p < 0.001). The AMT4 had a predictive efficiency of 91% and ranked 7 = /210 possible four-item combinations. CONCLUSIONS: The AMT4 may be useful in the initial assessment of cognition in elderly patients, with little loss of accuracy in detecting marked cognitive impairment when compared to the AMT.

Aged↗
PubMed1995

Utilization of laboratory resources: developments in knowledge-based ordering systems.

This paper describes two rule based decision support systems. The first system is used to screen incoming test requests for adequacy on the basis of signs and symptoms volunteered by the requesting GPs. The system was tested using a database of 794 requests for a TSH test. About 17% of the test requests were correctly identified as unnecessary. In total, 0.5% of the tests were incorrectly labelled as unnecessary. This concerned 4% of the patients that appeared to have hyperthyroidism and 23% of the patients that appeared to have hypothyroidism on the basis of TSH and FT4 results. The other system is a rule-based clinical decision support system for the requesting of laboratory investigations, originally designed for use at a hospital within the UK, that was implemented in a predominantly French-speaking hospital in Belgium. This involved the modification of the system to allow multilingual operation, and also the implementation of a completely new set of investigation protocols. The purpose of this study was to assess the transferability, both of the system itself, and of its benefits. The system was introduced gradually and has only recently been in full operation. However, the findings from the first months of routine use of the system indicate that the transfer of the system to a different clinical environment has been successful. Although it is too early to assess fully the impact on laboratory utilization, the clinicians believe that it is improving the appropriateness of investigations.

Artificial Intelligence↗
PubMed1994

Effects of a computerised protocol management system on ordering of clinical tests.

OBJECTIVE: To assess the effects of a computerised protocol management system on the number, cost, and appropriateness of laboratory investigations requested. DESIGN: A before and after intervention. SETTING: A supraregional liver unit in a teaching hospital. PATIENTS: 1487 consecutive patients admitted during 1990 and 1991 (one year before and one year after introduction of the system). INTERVENTION: Introduction of a computerised protocol management system on 1 January 1991. MAIN MEASURES: The number and cost of clinical chemistry tests requested per patient day. RESULTS: The total number of clinical chemistry tests requested per patient day by the unit declined 17% (p < 0.001, Student's t test) and of out of hours tests requested per patient day from 0.31 to 0.16, 48% (p < 0.001; Mann-Whitney U test), resulting in a 28% reduction (p < 0.001) in direct laboratory expenditure per patient-day. Overall, the number of tests per admission decreased by 24% (p < 0.001; Mann-Whitney U test). CONCLUSION: Use of the computerised protocol management system resulted in closer compliance with the protocols and a significant reduction in the overall level of requesting. IMPLICATIONS: Although similar systems need to be tested in other clinical settings, computerised protocol management systems may be important in providing appropriate and cost effective health care.

Clinical Laboratory Techniques↗
PubMed1993

Is serum creatine kinase:aspartate aminotransferase ratio useful for diagnosing acute myocardial infarction in elderly patients?

AIM: To evaluate the usefulness of the serum creatine kinase: aspartate aminotransferase (CK:AST) ratio in differentiating between myocardial and non-myocardial increases in serum creatine kinase activity in the elderly. METHODS: A three month prospective study of all patients admitted to an acute geriatric unit who were clinically assessed and investigated with electrocardiograms and measurement of CK, AST, and lactate dehydrogenase (LDH) activities on the first three days of admission. Excluding those with liver disease and alcohol misuse, patients with increased CK activity were then classified into four groups depending on whether they had fallen or had an acute myocardial infarction (AMI), or both. RESULTS: 270 patients were evaluated. CK activity was raised in 86 (31%) patients on any of the first three days of admission. Of these, 31 had fallen, 19 had an AMI, and five had both fallen and sustained an AMI. The CK:AST ratio, on all days, was higher (p < 0.05) in those who had fallen. On the second and third days, the CK:AST ratio was higher (p < 0.01) in those patients who did not have an AMI. The overlap, however, between these groups was large. CONCLUSIONS: These results did not allow discrimination to be made between myocardial and skeletal sources for increased CK activity. The CK:AST ratio is, therefore, of limited use when applied to the diagnosis of AMI in elderly patients. Clinical evaluation rather than the pattern of enzyme change is more likely to determine the cause of increased CK activity.

Accidental Falls↗
PubMed1992

Modifying the request behaviour of clinicians.

AIM: To evaluate whether the feedback of laboratory use and cost data to clinicians modifies their request behaviour. METHODS: Over two years the effect of monthly feedback of clinical chemistry test use and revenue expenditure to three consultant physicians on their clinical chemistry and haematology requesting patterns was evaluated. Two physicians who received no information served as controls. RESULTS: Feedback over one year led to an immediate and sustained decrease of 15%, 27%, and 21% in clinical chemistry requests (p less than 0.01), tests (p less than 0.001), and revenue expenditure (p less than 0.001), respectively, and a 10% reduction in haematology tests (p less than 0.05) per outpatient visit. These changes persisted in the six months after the feedback was stopped. CONCLUSIONS: These results suggest that feedback of laboratory data to clinicians modifies their request behaviour and that supplying clinicians with information on what they do can influence the way they make decisions.

Clinical Laboratory Techniques↗
PubMed1991

Feedback of laboratory usage and cost data to clinicians: does it alter requesting behaviour?

In a 1 year prospective study we evaluated the effect of feedback of laboratory data on the requesting behaviour of physicians in general medicine. Data on within-hours and out-of-hours clinical chemistry laboratory usage and revenue expenditure for inpatients and outpatients, expressed in terms of clinical workload, were supplied monthly to a group of three consultant physicians in general medicine. With these data the physician could monitor his performance over a period of time and compare it with that of his peers. Two consultants in general medicine who received no information served as controls. Over a period of 6 months, there was a 25%, 13% and 18% decrease in tests (P less than 0.01), requests (P less than 0.05) and revenue expenditure (P less than 0.01) per outpatient visit, respectively, in the intervention group of physicians following the introduction of feedback when compared to their baseline period and to the control group. The decrease (P less than 0.01) was in the commonly requested and 'seemingly cheap' tests. There was no significant change in laboratory use and expenditure on inpatients. The feedback of laboratory data was acceptable to the physicians, raised their awareness of laboratory usage and costs and decreased laboratory workload and expenditure.

Feedback↗
PubMed1990

Cardiac enzyme changes in elderly fallers.

The pattern of enzyme changes in elderly fallers admitted to an acute geriatric unit was investigated. Creatine kinase (CK), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) activities were measured daily for 3 days after admission in all patients in whom a fall preceded admission. Of 270 patients, 52 (19%) had fallen prior to admission, of whom five (10%) had an acute myocardial infarction (AMI). In fallers without an AMI in whom a history was available, CK and AST activities were significantly higher (p less than 0.05) in patients who had spent more than 1 hour on the floor than in those who had spent less than 1 hour. No other clinical factor affected enzyme activities. CK and AST activities were raised in 66% and 40%, respectively, of fallers without an AMI. Elevation of CK and AST activities in elderly fallers is likely to be a result of the fall itself rather than of an AMI.

Accidental Falls↗
PubMed1990

The effective use of cardiac enzymes and electrocardiograms in the diagnosis of acute myocardial infarction in the elderly.

The diagnosis of acute myocardial infarction (AMI) in the elderly is difficult and often depends on the results of investigations. In a 3-month prospective study, 270 patients admitted to an acute geriatric unit were studied to determine the most effective diagnostic strategy for the diagnosis of AMI, and to assess the value of screening acute geriatric admissions for AMI. Patients were assessed clinically and investigated with serial electrocardiograms and measurements of serum creatine kinase (CK), aspartate aminotransferase (AST), and lactate dehydrogenase activities on three consecutive days after admission. Measurement of serum activity of CK and AST had a diagnostic sensitivity of 100% and specificity of 86.8% for AMI. This was the optimum combination of cardiac enzymes in the diagnosis of AMI. Although electrocardiograms on the first two days of admission had a low diagnostic sensitivity (33.3%) their usefulness was their high positive predictive value (100%) when characteristic of an AMI. AMI was considered in the differential diagnosis of 79 patients (29%). All 25 patients (9%) who had an AMI were in this group, and therefore screening all geriatric admissions for AMI is not clinically justified.

Aged↗