Gentamicin Pescribing Audit Project

 Last week I presented the results of the audit project I've been working on in the hospital where I work as part of the monthly medical division clinical governance meeting. Audit is an important process whereby everyday practice is compared to the ideal standards and practice. I wanted to audit prescribing of gentamicin in the hospital. It is an antibiotic which has nephrotoxic and ototoxic effects if given in high concentrations. Monitoring of blood levels is very important to ensure safe prescribing and levels should ideally be documented on a monitoring chart, with the dose calculated based on the patient's weight and renal function. Duration of treatment should not exceed 72 hours except in exceptional circumstances. I audited this process and found that in more than half of cases at least one of my outcome measures were not being completed correctly. In these patients, it was more likely that renal function would be affected, leading to my suggestion that patients will directly benefit form improved compliance with these monitoring protocols. The plan is for a new gentamicin prescribing and monitoring chart to be introduced in the hospital in August 2012 which will hopefully improve compliance. There's a lot coming up over the next couple of months (the wedding, portfolio hand-in etc) so I'd imagine that posts on here are going to be a bit more sparse over the next while. More to follow...

Notes From On-line Modules - Monday 16th April

Notes From On-line Modules - Monday 16th April

1. Diabetes Management + Insulin Types

Novorapid, Actrapid, Humulin S and Humalog are fast acting, short duration. Humulin M3 is fast acting, long lasting. Humulin I and Insulatard peak slowly and are long lasting. Insulin Detemir and Insulin Glargine are very long acting. In patients in DKA requiring insulin for infusion - short acting insulin eg. Actrapid should be used.

2. Diabetes Management: Prescribing Insulin Safely

If unsure about the correct type of insulin which a patient normally receives - clarify with the GP. If discharging a patient on Insulin in whom steroids have been stopped - advise the patient to increase the frequeny of blood glucose monitoring (risk of hypoglycaemia increases). If discharging a patient on a new insulin regime they should ideally be seen by the diabetes team as an outpatient in 1-3 days.

3. Information Governance

Next of kin does not have a 'right to know' information about a patient. In a "serious offence" situation the doctor can disclose information about a patient to the police as acting in the "public interest". Inadequate clinical records are cited as a factor in approximately 80% of indefensible medico-legal cases. Ward round notes should include: summary of the case, discussion with the patient, examination findings, relevant investigations, impression/diagnosis and management plan.

4. Palliative Management of Nausea

Chemotherapy induced nausea involves the neurotransmitted 5HT3 - large amounts are released when the gut is irradiated. Ondanstron is a powerful 5HT3 antagonist. Opioids can stimulate the chemoreceptor trigger zone (CTZ) - this is best treated with either haloperidol or metoclopramide. Cyclizine has no effect on the CTZ. Cyclizine acts upon the vomiting centre in the brain. Side effects of ondansetron and cyclizine include constipation. For nausea caused by constipation metoclopramide would be the drug of choice. For nausea induced by hypercalcaemia, this should be treated with haloperidol.

5. Pharmacy: Adverse Drug Reactions (ADR)

These are surprisingly common! And can be fatal! Most commonly they are caused by NSAIDS, diuretics (renal impairment, hypotension and electrolyte disturbance) and anti-coagulants. The main way to report adverse drug reactions is via the "Yellow-Card Scheme". In the BNF new medicines are marked with a small black triangle (these often have a higher rate of ADRs. All health care professionals can report adverse drug reactions using this scheme.

6. Pharmacy: Prescribing in Pregnancy

A teratogen is an agent or factor which can cause congenital malformations. Nearly all drugs cross the placenta. The most susceptible period is 3-8 weeks post-conception. Ideally best practice is to rationalise and alter medication prior to pregnancy through planning (eg. stopping certain anti-epileptic drugs such as sodium valprotae). Sources for doctors if they are concerned about the effects of drugs in pregnancy include: the BNF, Toxbase and EMC (http://emc.medicines.org.uk/emc). Trimethorim, for example, is not recommended in pregnancy. Cyclizine is a widely used anti-emetic in pregnancy for the treatment of nausea.

Filaggrin and Medical Eponyms

Moness Country Club, Aberfeldy

Had a great weekend away over Easter with the family staying up in Aberfeldy for the JK orienteering held over the Saturday and Sunday. Finished 10th on my course but still took over 2 hours both days so lots of space for improvement!

In 2008 for my BMSc in Genetics I carried out some research on the role of genes coding for skin barrier protiens, specifically the keratins. At the time the lab was involved in some break-through research regarding the role of the protein, filaggrin. It is now estimated that as many as one in ten European people have a mutation in the filaggrin gene which results in a dysfunctional skin barrier. This can manifest itself as painful skin fissures in the heels, lips and ears. It is recommended that moisturisers are applied liberously during times of low humidity (such as winter), to help maintain skin hydration. The results of this recent study are summaries in the BMJ this week in the 'Minerva' section.

Medical eponyms are commonplace in medical school or clinical examinations but rarely heard in everyday clinical practice. Des Spence (Glasgow GP who writes a weekly column in the BMJ) visits this topic this week. He argues a time may have come to evaluate the evidence of the usefulness of clinical eponyms and to move on that the 'classic' medical examination taught systematically to all medical students. Of course, all students must learn how to examine patients effectively - this is a key skill for every new doctor, but is it time we updated the clinical examination. Could the increasing use and availabilty of bedside imaging (eg. portable ultrasound) be used to improve clinical practice? Dr Spence thinks we should teach all medical students how to ultrasound patients. Imagine a world with portable ultrasounds in A&E to examine the abdomens of surgical patients, or in the coronary care unit to examine the heart function of new cardiology patients? So much time could be saved! Which would be more sensitive at picking up a physical sign eg. hepatomegaly - the scanner, or the doctor's palm, or both combined?

 

Craig a Barns - JK Day 3

Lung Cancer and Acute Charcot Foot

Detecting Lung Cancer - A man is admitted to the hospital with a history of weight loss, increasing tiredness and chronic cough. He has been a smoker for more than fifty years. After initial investigations, a CT scan is ordered which shows advanced metastatic bronchial carcinoma. At this point the condition is effectively incurable and the prognosis is poor. Scotland has one of the highest rates of lung cancer in the world and as I've written previously on this blog - early detection is crucial to improve outcomes. A large new trial is set to take place in Scotland to assess the reliability of a blood-test for early detection of lung cancer. 10,000 people who have smoked more than 20 cigarretes for more than 20 years (>20 pack years) are being entered into the trial. A screening trial in the US previously looked at 53,000 smokers and found that CT scanning led to early detection and improved outcomes. The problem with CT scanning is that it is expensive and has a false positive rate of approximately 50% (the test suggests the presence of disease but turns out to be incorrect). This new blood test which has been developed can detect about half of lung cancers with a false positive rate of only 7%. The full results of the trial are expected in 2014. In the meantime, chest X-rays are also good imaging modalities for early detection of malignancy and are generally performed on all acute medical hospital admissions (see above example). On another note, further evidence has emerged now to show that aspirin can help to prevent cancer, particularly colorectal cancer, when associated with controls not taking daily aspirin, over a period of five years. On the balance however, patients taking daily aspirin are at higher risk of haemorrhage therefore this needs to be taken into account. It's too early to say that everyone should take aspirin to reduce their risk of cancer.

Charcot Foot - An easily missed diagnosis. A type I diabetic patient is admitted with a warm, swollen red foot. The complications from his diabetes include peripheral neuropathy and nephropathy. Plain X-rays of the foot show metatarsal neck fractures. The patient is advised not to weight bear. MRI confirms a diagnosis of acute charcot joint. This is a destructive joint condition which usually occurs in diabetic patients who have reduced sensory innervation. Even in a diabetic foot clinic, one study showed that 19 of 24 cases were not diagnosed correctly. Differential diagnosis includes cellulitis, gout, DVT or ankle sprain. Failure to diagnose the condition early can lead to joint deformity, particularly if the patient continues to weight bear. Pain is not always present due to peripheral neuropathy. Infection and neuro-arthropathy are not mutually exclusive and may co-exist. Important first line investigations include findings of fractures or bony misalignment in the absence of any obvious trauma. MRI is the most useful diagnostic test. These patients should be advised not to weight bear, and should have their foot in a cast for three to six months ideally. This is an easily missed diagnosis and one to look out for!

Changes to GP Training in the UK

The 'Squinty Bridge' - Ran across it on Sunday

In the BMA News this week:

 

The Scottish Government has suggested that it might welcome 'something different' and a 'different approach' when it comes to reforming the NHS pensions scheme. The outcome of the ballot on industrial action is still awaited. 

Academic medicine and public health medicine are the careers in the spotlight, with redundancies being made in senior clinical lecture posts in London and the warning that public health trainees face a lack of substantive posts to enter into at the end of their training. It seems that in a tough financial climate, these are the kinds of areas taking the biggest hit.

Today's been the hottest day in Scotland in March since the records began (22.9'C in Aboyne, near Mum and Dad in Banchory!). In Wales, the government is considering offering free sun-tan lotion to under 11 year old children. This is being considered to help protect children from UV radiation, along with other measures such as better provision of shade in schools.

GP training has changed recently to update the existing three year specialty training programme, to a four year programme. Apparently the existing programme is one of the shortest in Europe and has left some trainees feeling 'competent but not confident'. The RCGP plan is to increase the training from three to four years. The cost of each trainee going through an additional year is approximately £63,500 and the extra cost of the whole current cohort of trainees doing an ST4 year is approximately £209 million. However, it is believed that this will help to create doctors who are less likely to refer people to hospital and more likely to rationalise inappropriate prescribing. Apparently a reduction of inappropriate prescribing of just 2 percent could save £164 million a year, whilst a reduction in the total number of in-patient days by just 1% (through less people being referred to hospital) could save £267 million a year. But just how useful will an extra year be? The argument for is that doctors training for longer will be more experienced and competent when they finish. The argument against is that this extra year will simply involve filling gaps in rotas in hospitals where there is no time for learning anyway. The jury's out on this one but there seem to be pretty strong opinions out there for both sides!

Should we Screen more Healthy Individuals for Cardiac Abnormalities?

 41 minutes into Tottenham and Bolton's FA cup game yesterday, Fabrice Muamba, the 23 year old Bolton mindfielder, suddenly collapsed. As the paramedics rushed to his attention, it became apparent that he had suffered from a cardiac arrest. CPR was commenced and the patient taken immediately by ambulance to the London Chest Hospital where cardiac output was re-established and he was admitted to the intensive care unit. According to statistics, every week in the UK 12 apparently fit and healthy individuals under the age of 35 die from an undiagnosed cardiac condition. Often this is brought on by extreme exercise, as happened in this case. Common causes include obstructive hypertrophic cardiomyopathy, long-QT syndrome and coronary artery abnormalities. A family history of sudden cardiac arrest should prompt further investigation in a healthy individual, particularly if they are about to start an exercise programme. Professional footballers all receive medical assessments before signing a contract but should we be screening more individuals? I'm meant to be running a marathon in seven months - maybe I should have some kind of screening assessment? Or would people prefer to get on with their lives, enjoy sport and accept the risk? Perhaps after what happened to Fabrice Muamba there will be an influx of worried healthy people wanting referred to a cardiologist or investigated further.

Other things which I've been reading about this week:

BMA announces paid shadowing for FY1 doctors - After lobbying the Department of Health, the BMA has announced that all newly starting FY1s this August will have a paid four day 'shadowing' period before starting work. I think that it is good that the Department of Health have recognised that this is a necessary implementation (not optional) for new doctors starting work and should therefore be counted as paid work. Hopefully this new plan will ease the stress of the new doctors starting in August and help to improve patient safety.

People over 65 years old should be screened for atrial fibrillation. A BMJ poll asked whether everyone over 65 be screened for atrial fibrillation. In the poll 61% of respondents answered yes. It seems that there are still high numbers of patients not being treated effectively for atrial fibrillation. Improved management of patients with this condition could greatly reduce the numbers of patients having a stroke each year.

A man with 'locked-in syndrome' has been granted permission by a high court judge to apply for a court declaration that would allow a doctor to kill him without risking a murder charge. He is arguing for voluntary euthanasia rather than assisted suicide. This whole issue is extremely complex - does a person have the right to end their life? Is there ever a case for someone to assist someone to end their life? The condition which this man has is truly awful but even if he is successful with his case, I do not think he will be able to find a doctor who would assist him to end his life.

And finally...I've been reading more in the BMJ Careers section about the topics which I've raised previously about out-of-hours care and the surplus of doctors in training. It seems increasingly likely that consultants in the future will be expected to provide more out-of-hours care including night shifts and weekends. Reading this is drawing me more and more towards pursuing the general practice career route!