Organisational approaches to quality improvement and quality management

There are a great many articles relevant to quality improvement in organisational and managerial literature; the following offer a taster. Broadly speaking, papers cover three areas: the measurement of quality improvement; information and its potential to improve quality and/or to raise its profile; and organisational consequences of management approaches including the increasing attention paid to organisation culture and values congruent with quality improvement. These literatures tend to draw on case studies or (what are presented as) exemplar organisations.

Scharitzer D, Korunka C. New public management: evaluating the success of total quality management and change management interventions in public services from the employees' and customers' perspectives. Total Qual Manag 2000;11:S941.

Abstract reproduced from original.

The aim of this study is the development of a monitoring approach covering and following up on the effects of total quality management and change in management interventions in public services from the employees' and customers' perspectives. The results should give managers in charge a clear idea of whether or not the steps taken in the restructuring process can be rated as successful from an internal and external evaluation perspective. The study is an empirical evaluation of a complex restructuring process in the public service sector in Austria. It was realised as a single case study conducted with a large public housing agency on the way to a more customer orientation. Extensive employee and customer satisfaction surveys were done to evaluate success.

Dewan NA, Daniels A, Zieman G, et al. The National Outcomes Management Project: a benchmarking collaborative. J Behav Health Serv Res 2000;27:431–6.

Abstract reproduced from original.

Traditional evaluation of health care quality usually involves the measurement of the structure, process, and outcome of care. Most quality improvement programmes involve a cycle that includes a setting of goals, a measurement of either process or outcomes, and a real-time or retrospective feedback of the results of data measurement. Benchmarking, a well known efficient business technology, can lead to practice innovations necessary to survive in an environment that has a need for decreasing cost and increasing quality. A novel use of benchmarking in managed ambulatory behavioral health care is proposed, and its application in a model collaborative outcome management project at more than 16 sites and nine states in the USA is discussed.

Gupta AK, Govindarajan V. Knowledge management's social dimension: lessons from Nucor Steel. Sloan Manag Rev 2000;42:71–80.

Abstract reproduced from original.

Building an effective social ecology—that is, the social environment within which people operate—is a crucial requirement for effective knowledge management. An effective knowledge machine must excel at two central tasks: creating and acquiring new knowledge, and sharing and mobilising that knowledge throughout the corporate network. To sustain competitive advantage, a company must give people incentives to transfer their knowledge. A look at the innovative steel company Nucor and others suggests how to build a knowledge sharing environment.

Bates DW, Gawande AA. The impact of the Internet on quality measurement. Health Aff 2000;19:104.

Abstract reproduced from original.

Consumers are eager for information about health. However, their use of such data has been limited to date. When consumers do consider data in making health care choices, they rely more on word of mouth reputation than on traditional quality measures, although this information has not necessarily been readily accessible. The Internet changes the exercise of quality measurement in several ways. First, quality information—including reputation—will be more readily available. Second, consumers will increasingly use it. Third, the Internet provides a low cost, standard platform that will make it much easier for providers to collect quality information and pass it on to others. However, major barriers still stand in the way of public access to quality information on the Internet as well as having that access actually improve patients' care. By all measures it matters where patients go for their medical care. However, beyond extreme generalities—for example, that teaching hospitals tend to have better outcomes than non-teaching hospitals, or that high-volume surgeons tend to do better than low-volume surgeons—patients have usually not had much guidance for making choices. Those who seek to choose carefully—and most do not—end up differentiating primarily by word of mouth reputation. Word of mouth has been strongly criticised as an unreliable measure of health care quality. Efforts to provide evidence-based information to guide consumers and providers have faltered, however. Critics question the value of the data provided, and few people have used them anyway. It is hoped that the Internet will change this state of affairs; to a great extent it may already be doing so, but not necessarily in the anticipated ways.

Staw BM, Epstein LD. What bandwagons bring: effects of popular management techniques on corporate performance, reputation, and CEO pay. Admin Sci Q 2000;45:523–56.

Abstract reproduced from original.

This paper examines some of the important organisational consequences of popular management techniques. Using informational reports on quality, empowerment, and teams, as well as a measure of the implementation of total quality management programmes, it was found that companies associated with popular management techniques did not have higher economic performance. Nevertheless, these same companies were more admired, were perceived to be more innovative, and were rated higher in management quality.

Savitz LA, Kaluzny AD, Silver R. Assessing the implementation of clinical process innovations: a cross-case comparison/practitioner application. J Healthc Manag 2000;45:366.

Abstract reproduced from original.

Clinical process innovations (CPI) are central to the ability of organisations to negotiate the challenges of cost containment and quality improvement, yet many CPI have not met expectations. Perhaps most alarming is that the dissemination and implementation of CPI is not well understood. This is the second of two articles addressing the dissemination and use of CPI in integrated delivery systems. This article discusses those factors that have been identified as either facilitating or impeding the various stages in implementing CPI and suggests some intervention strategies to enhance opportunities for continuous CPI. Identifying the process and the factors driving the implementation of CPI is only part of the challenge. The adequate development of CPI fully to meet current challenges will require managers to re-examine existing paradigms and values influencing their actions to date. Within this context, the necessary staging of the innovation process within the life cycle, developing partnerships both within and outside the organisation to gather the necessary resources and support, and multidimensional performance monitoring and feedback can prepare organisations and managers better to face the reality of managing the innovation process. Innovation is fundamental to organisational survival and is particularly critical to the ability of healthcare organisations to function in an increasingly competitive and dynamic environment. “Innovate or fail” has become the leading challenge to organisations seeking to handle the double-edged sword of simultaneous cost containment and competitive advantage through quality improvement

Detert JR, Schroeder RG, Mauriel JJ. A framework for linking culture and improvement initiatives in organizations. Acad Manag Rev 2000;25:850–63.

Abstract reproduced from the original.

This article presents a synthesis of the general dimensions of organisational culture used most commonly in extant research and outlines how these general dimensions correspond to the specific values and beliefs underlying total quality management practice. It is argued that the relationship between culture and implementation of new behaviors and practices has not been adequately explored because of the lack of a comprehensive framework for defining and measuring organisational cultures. The framework presents a necessary step in moving toward culture as a useful explanatory concept in organisational research.

Quality improvement reports

The following is the first quality improvement report to have been published by the BMJ.

Ripouteau C, Conort O, Lamas JP, et al. Effect of multifaceted intervention promoting early switch from intravenous to oral acetaminophen for postoperative pain: controlled, prospective, before and after study. BMJ 2000;321:1460–3.

Abstract reproduced from original

Problem—Need to improve the efficiency of postoperative pain management by early switching from intravenous to oral acetaminophen.

Design—Implementation of local guidelines aimed at improving nurses' and doctors' behaviour. A controlled, prospective, before and after study evaluated its impact on appropriateness and costs.

Background and setting—Orthopaedic surgery department (intervention) and all other surgical departments (control) of a university hospital. Five anaesthetists and 30 nurses of orthopaedic department participated in study.

Key measures for improvement—Reducing number of acetaminophen injections per patient, reducing consumption of acetaminophen injections; cost savings over a one year period.

Strategies for improvement—Multifaceted intervention included a local consensus process, short educational presentation, poster displayed in all nurses' offices, and feedback of practices six months after implementation of guidelines.

Effects of change—Mean number of acetaminophen injections per patient decreased from 6.81 before intervention to 2.36 six months after. Monthly consumption of acetaminophen injections per 100 patients decreased by 320.9 (95% confidence interval 192.4 to 449.4) in intervention department and remained unchanged in control departments. Annual cost reduction was projected to be £15 100.

Lessons learnt—Simple and locally implemented guidelines can improve practices and cut costs. Educational interventions can improve professionals' behaviour when they are based on actual working practices, use interactive techniques such as discussion groups, and are associated with other effective implementation strategies.

Pitter D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307–12.

Abstract adapted from original.

Hand hygiene, either by hand washing or hand disinfection, is the most important measure to prevent nosocomial infections and yet poor levels of hand hygiene are noted among healthcare workers. This study monitored the effectiveness of a hospital-wide programme to promote hand hygiene and, in particular, the use of alcohol based hand rubs. The programme included displaying colour posters that emphasised the importance of hand cleansing, placing alcohol based hand rubs in convenient sites and beside beds, and developing an easy to carry bottle of hand rub solution. Compliance with hand hygiene measures improved from 48% to 66%. While hand hygiene improved significantly among nurses and nursing assistants, it remained poor among doctors. During the same period overall nosocomial infection decreased from a prevalence of 16.9% to 9.9%. MRSA transmission rates also decreased.

Kaneko A, Taleo G, Kalkoa M, et al. Malaria eradication on islands. Lancet 2000;356:1560–4.

Abstract adapted from original.

Vanuatu consists of 80 inhabited islands in the Southwest Pacific, with hypoendemic and mesoendemic malaria and suitable conditions for sustained parasite elimination. A programme was introduced to try to eliminate malaria. Weekly mass drug administration of chloroquine, pyrimethamine/sulfadoxine, and primaquine was carried out on the entire population. Simultaneously with the administration of drugs, permethrin impregnated bednets were distributed to the entire population. Larvivorous fish were also introduced into several identified breeding sites of the Anopheles farauti mosquito. The subsequent surveys showed sustained interruption of malaria transmission. The programme demonstrated that malaria on isolated islands can be eliminated with well adapted short term mass drug administration and sustained vector control if there is a high degree of community participation.

Younger D, Martin G. Dementia care mapping: an approach to quality audit of services for people with dementia in two health districts. J Adv Nurs 2000;32:1206–12.

Abstract adapted from original.

Background—There are problems in evaluating the quality of services for those with dementia. Such clients may not be able to impart their perspective reliably. Good dementia care enables the individual to feel supported, valued and socially confident. Evaluation tools available for assessment of dementia care tend to focus on quantity of activity rather than on levels of interpersonal interaction and well being. However, the dementia care mapping (DCM) approach attempts to measure the positive and negative aspects of the psychosocial environment, producing richer data than by other observational methods. There is no other tool that puts the service user at the centre of the care process.

Methods—Using a non-participatory method, the DCM was used in six formal care settings within two health districts in the UK. This included two day units, two assessment units, and two continuing care units. The observations totalled 12 hours per unit. After each 5 minutes of observation the observer coded the behaviour, made a qualitative judgement called well-being/ill-being value (WIB), and assessed the possibility of recording Personal Detractors (PDs) which are behaviours associated with loss of self-esteem. Data analysis was carried out using a scoring system of the WIBs, a diversity factor, and the Dementia Care Index (DCI).

Results—A comparative analysis was drawn between the various care settings. The DCI gives a benchmark to the units to measure quality. The scores in this study ranged from 72 (very high) to 11 (radical changes required). The diversity factor of the choice and range of activity ranged from 8 in one to 2 in another. The unit with the second highest dependency levels had the second highest score in the DCI for an inpatient unit and a wider diversity rating than the two other units. This indicates that high dependency does not necessarily mean lower quality of person-centred care. It was apparent that care settings can differ in style, size provision, patient dependency, and staffing levels. The results highlight the need for a wider range of activities to promote person-centred care and a suggested route to the improvement in quality of life of older people.

Conclusions—The DCM exercise provided baseline data, identifying areas of excellence in practice and areas where practice can be enhanced. As a result of this study there is now an awareness for staff to participate in the quality circle of building on the audit process, to emphasise issues such as stimulation and exercise for the clients, and to contribute to discussions on routes of improvement.

Patient education

This study presents findings of the current practice of medication education for patients. They have implications for augmenting the current practice of medication education and promoting patient/family participation in the process.

Latter S, Yerell P, Rycroft-Malone J, et al. Nursing, medication education and the new policy agenda: the evidence base. Int J Nurs Stud 2000;37:469–79.

Abstract reproduced from original.

Background—Current social and demographic trends, combined with the `new policy agenda', highlight the importance of nurses' roles in educating patients about medication. In the absence of previous research investigation, this study set out to explore nurses' current contribution to medication education and the clinical contextual factors that influence current practice.

Method—The evidence base for effective medication education was established from reviews of literature and focus groups with key informants. Nurses' practice was investigated using a case study approach in seven clinical areas representing adult, care of the older person, mental health, and community nursing contexts. Methods used to collect data were audio recordings (n=37) and observation (n=48) of nurse–patient interactions about medication, post-interaction interviews with nurses (n=29), post-interaction interviews with patients (n=39), analysis of relevant written documentation, and researcher observation and field notes. Data sources within each case were subjected to systematic content analysis in order to identify current practice and contextual influences within each case. Cross-case analysis was also employed in order to identify explanations for any differentiation in practice.

Results—Findings indicate that nurses' contribution to medication education is commonly limited to simple information about medicines involving the name, purpose, colour, number of tablets, and the time and frequency that medications should be administered. Nurses' practice in two of the seven clinical areas was characterised by interactions that more closely demonstrated features of what is known to constitute more comprehensive and effective medication education. Analysis of contextual influences within and between cases allowed explanations to be derived for the types of medication education interactions observed. These concerned patient characteristics, perceived and expressed preferences of patients for information, characteristics of the nurse–patient relationship, lack of time and high workload, and the philosophy of care within the clinical area. In all clinical areas, nurses were not explicitly and judiciously using available evidence to inform their medication-related interactions.

Conclusions—It is recommended that nurses review contextual issues that either facilitate or promote the practice of medication education in their own clinical areas as well as consideration to the evidence base for effective medication education. It is highlighted that this joint process will contribute to maximising the nurses' role in this important health education activity and thus potentiate health gain for patients and reduce financial loss to the health service.

Evidence based care

Ensuring that health care practice and policy are evidence based requires a regular and rigorous critique of research evidence available to date. Presented below are brief summaries of research papers that can support and inform improvements in quality of health care. Papers have been classified under broad subject areas.

MANAGEMENT OF THE CHRONIC AND TERMINALLY ILL PATIENT

Mant J, Carter J, Wade DT, et al. Family support for stroke: a randomised controlled trial. Lancet 2000;356:808–13.

Abstract adapted from original.

The psychosocial impact of stroke upon families is increasingly recognised. This trial sought to gather evidence for the effectiveness of support services provided by the Stroke Association for stroke patients and their carers. The nature of this support involved an average of one hospital visit, one home visit, and three telephone calls by a family support organiser. Information leaflets and a contact number for the family support organiser were also provided. Statistically significant benefits were achieved for carers in measures of mental health and physical well being. Patients' knowledge about stroke, disability, handicap, quality of life, and satisfaction with services and understanding of stroke did not differ between groups. Fewer patients in the intervention group saw a physiotherapist after discharge. There were no significant effects upon patients.

Kalra L, Evans A, Perez I, et al. Alternative strategies for stroke care: a prospective randomised controlled trial. Lancet 2000;356:894–9.

Abstract adapted from original.

The objective of this study was to compare the efficacy of stroke unit, stroke team, and domiciliary stroke care in reducing mortality, dependence, and institutionalisation in patients with moderately severe strokes. A single blind, randomised, controlled trial was undertaken in 457 acute stroke patients randomly assigned to stroke unit, general wards with stroke team support, or domiciliary stroke care The primary outcome measure was death or institutionalisation. Patients managed on the stroke unit were less likely to die or be institutionalised than those managed at home or managed by the stroke team at 3, 6, and 12 months. The important difference between settings was that only patients in the stroke unit received dedicated 24 hour specialist care with a more structured and consistent approach to stroke related problems, early rehabilitation, and secondary prevention.

Jørdhoy MS, Fayers P, Saltnes T, et al. A palliative-care intervention and death at home: a cluster randomised trial. Lancet 2000;356:888–93.

Abstract adapted from original.

There is evidence to suggest a preference by terminally patients to die at home. An intervention programme in Norway was developed to enable such patients to spend more time at home and to die there if they preferred. Close cooperation was needed with the community healthcare professionals who acted as the principal formal care givers, and a multidisciplinary consultant team coordinated the care. A cluster randomised trial was designed to assess the intervention effectiveness compared with conventional care. 434 patients (235 assigned intervention and 199 conventional care) were enrolled who had incurable malignant disease and an expected survival of 2–9 months. More intervention patients than controls died at home (25% v 15%). The time spent at home was not significantly increased, although intervention patients spent a smaller proportion of time in nursing homes in the last month of life than did controls (7.2% v 14.6%). Hospital use was similar in the two groups.

Lamping DL, Constantinovici N, Roderick P, et al. Clinical outcomes, quality of life, and costs in the North Thames dialysis study of elderly people on dialysis: a prospective cohort study. Lancet 2000;356:1543–50.

Abstract adapted from original.

Age has been used to ration dialysis, although not always explicitly, despite the lack of rigorous empirical evidence about how elderly people fare on dialysis. This 12 month prospective cohort study sought to assess the outcomes in patients aged 70 years or over with end stage renal failure. One year survival and disease burdens were measured. The 1 year survival rates for elderly patients (72% for all patients who started dialysis and 81% for those who survived 90 days) compared very favourably with the 63% and 85% survival rates reported in a study of patients of all ages. Although survival is lower in patients aged over 80 years, comorbidity is a more important determinant of outcome than age. Age alone should not be used as a barrier to referral and treatment, and dialysis can offer considerable benefits to elderly people.

Karlsson S, Bucht G, Rasmussen B, et al. Restraint use in elderly care: decision making among registered nurses. J Clin Nurs 2000;9:842–52.

Abstract adapted from original.

Background—Decision making in the use of physical restraint requires a balance between professional judgement and patient safety and poses a moral dilemma for staff. This study investigated the intricacies of nurses' reasoning behind physical restraint use, the relationship between nurses' attitudes, and decisions regarding its use.

Methods—Thirty registered nurses from two nursing homes in Sweden were involved in this two part study. Firstly, in order to examine nurses' reasoning behind physical restraint use, a semi-structured interview approach was used and its ethos pertained to a clinical vignette. This vignette described a fall prone person with dementia who refused to be physically restrained. The nurses were asked to comment on how they would react to this situation. Their rationale was probed further by presenting situational and directive type scenarios and by having staff provide their arguments in respect of these issues. The data were subject to a content analysis. Secondly, the association between the decision made and nurses' attitudes towards physical restraint use was measured by the Perceptions of Restraint Use Questionnaire (PRUQ). Data were analysed using SPSS.

Results—Twenty one nurses at first considered they would disregard the patient's wish and use restraint in the given situation while nine felt they would not. When new relevant facts were provided all nurses except two were ready to change their decision. Decisions to remove restraints were based on arguments of avoiding harm to the patient, respecting patient autonomy, and the willingness of nurses to take risks. Decisions to restrain were based on lack of time, duty to obey an order, acting in the patient's best interest, and acting in accordance with family wishes. A statistically significant difference in attitude scores (p≥0.05) was found between nurses who at first would remove the restraint and those who would not (median (range) scores 30.0 (19–52) v 46.0 (29–79)), i.e. those who decided to use the restraint had a higher mean score on the attitude scale.

Conclusions—Nurses' use of physical restraint in gerontology is influenced by variables such as work related issues and their willingness to take risks. Results indicate that nursing staff are influenced by what is best for themselves. The study also suggests the need for a holistic policy to promote restraint reduction that would be based on individualised care, take consideration of professional and legal issues, patient/family involvement and be supported by in-service education.

PREVENTION OF DISEASE AND INJURY

Hayden FG, Gubareva LV, Monto AS, et al. Inhaled zanamivir for the prevention of influenza in families. N Engl J Med 2000;343:1282–9.

Abstract adapted from original.

As prophylaxis against influenza in families, amantadine and rimantadine have had inconsistent effectiveness, partly because of the transmission of drug resistant variants from treated index patients. This study was a double blind, placebo controlled study of inhaled zanamivir for the treatment and prevention of influenza in families; 337 families were randomly assigned to receive either placebo or zanamivir. The family member with the index illness was treated with either 10 mg inhaled zanamivir or placebo twice a day for 5 days and the other family members received either 10 mg zanamivir or placebo once a day as prophylaxis for 10 days. Zanamivir provided protection against both influenza A and influenza B. There was no evidence of the emergence of resistant influenza variants. Among the subjects with index cases of laboratory confirmed influenza, the median duration of symptoms was 2.5 days shorter in the zanamivir group than in the placebo group. Zanamivir was well tolerated.

Sutter RW, Jaffer A, Suleiman M, et al. Trial of a supplemental dose of four poliovirus vaccines. N Engl J Med 2000;343:767–73.

Abstract adapted from original.

The immunogenicity of oral poliovirus vaccine (OPV), particularly the type 3 component, is lower in infants in most developing countries than in infants in industrialised countries. This multicentre trial in Oman sought to evaluate the response to a supplemental dose of four poliovirus vaccine formulations. At 9 months of age infants were randomly assigned to receive inactivated poliovirus vaccine (IPV), trivalent OPV, or monovalent type 3 OPV. All of the infants had previously received five doses of OPV. At 30 days there were no significant increases in type 3 seroprevalence or in the median antibody titre in the groups of infants who received OPV. Among the recipients of IPV, type 3 seroprevalence increased from 87.8% at enrollment to 97.1% at 30 days (p<0.001). The rapid initial increase in the antibody titre suggests a secondary immune response. A supplemental dose of IPV therefore offers excellent immunogenicity and leads to increases in the titre of antibodies against type 3 poliovirus, whereas supplemental doses of the oral vaccines do not have these effects.

Kannus P, Parkkari J, Niemi S, et al. Prevention of hip fracture in elderly people with use of a hip protector. N Engl J Med 2000;343:1506–12.

Abstract adapted from original.

Hip fractures are a major cause of disability, functional impairment, and death in elderly people and this study sought to determine whether external hip protectors could reduce the risk of these injuries. 1801 ambulatory frail elderly adults were randomly assigned either to an intervention group wearing the hip protector or to a control group. During the study 13 of the 653 subjects in the hip protector group had a hip fracture compared with 67 of the 1148 subjects in the control group. The risk of hip fracture was reduced by 60% in the intervention group. Only 41 persons need to use the hip protector for 1 year for one fracture to be prevented.

Mandel JS, Church TR, Bond JH, et al. The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med 2000;343:1603–7.

Abstract adapted from original.

Annual and biennial testing significantly reduces the mortality from colorectal cancer as a consequence of the earlier detection and surgical removal of malignant colorectal tumours. However, this study sought to test the observation that occult blood screening may also reduce the incidence of colorectal cancer by the detection and removal of premalignant adenomatous polyps. A total of 46 551 subjects were randomly assigned to annual screening, biennial screening, or usual care. The cumulative incidence ratios for colorectal cancer in the screening groups compared with the control group were 0.80 and 0.83 for the annual screening and biennial screening groups, respectively. This significant reduction in the incidence of colorectal cancers is likely to improve the cost effectiveness of screening.

Bergman L, Beelen MLR, Gallee MPW, et al, and the Comprehensive Cancer Centres ALERT Group. Risk and prognosis of endometrial cancer after tamoxifen for breast cancer. Lancet 2000;356:881–7.

Abstract adapted from original.

This paper reports the findings of a nation wide case-control study exploring the risk and prognosis of endometrial cancer after tamoxifen use for breast cancer. Information on tamoxifen use and other risk factors for endometrial cancer was obtained from 309 women with endometrial cancer after breast cancer and 860 matched controls with breast cancer but without endometrial cancer. The risk of endometrial cancer increased with longer duration of tamoxifen use, with relative risks of 2.0 for 2–5 years and 6.9 for at least 5 years compared with non-users. Long term tamoxifen users were also shown to have a worse prognosis of endometrial cancers, which seemed to be due to less favourable histology and higher stage. However, the benefits of tamoxifen on breast cancer survival far outweigh the increased mortality from endometrial cancer. Nevertheless, the authors seriously question widespread use of tamoxifen as a preventive agent against breast cancer in healthy women.

Zornberg G, Jick H. Antipsychotic drug use and risk of first-time idiopathic venous thromboembolism: a case-control study. Lancet 2000;356:1219–23.

Abstract adapted from original.

Antipsychotic drugs are widely used in medicine and psychiatry, but little attention has been focused on the potentially fatal adverse drug reaction of venous thromboembolism, which includes pulmonary embolism and deep vein thrombosis. The aim of this study was to assess this risk in users of conventional antipsychotic drugs who had been diagnosed with first time, idiopathic venous thromboembolism. Forty two individuals with idiopathic venous thromboembolism and 172 matched controls were compared for risk of current and recent use of antipsychotic drugs. Current exposure to conventional antipsychotic drugs was associated with a significantly increased risk of idiopathic venous thromboembolism compared with non-use (adjusted odds ratio 7.1). Although no difference was found between phenothiazines, thioxanthenes, or other conventional antipsychotic drugs, low potency antipsychotic drugs such as chlorpromazine and thioridazine were more strongly associated with venous thromboembolism (odds ratio 24.1) than were high potency antipsychotic drugs such as haloperidol (3.3). The risk for venous thrombosis was highest during the first few months of conventional antipsychotic drug use.

Kuzu N, Ucar H. The effect of cold on the occurrence of bruising, haematoma and pain at the injection site in subcutaneous low molecular weight heparin. Int J Nurs Stud 2000;38:51–9.

Abstract adapted from original

Background—The occurrence of bruising and haematoma at the injection site of patients due to low molecular weight heparin (LMWH) preparations has been evaluated in a number of studies. Various factors appear to influence the occurrence of haematoma, bruising, and pain, including injection technique, selection of injection site, and the use of wrong size injection needles. A number of studies have made recommendations concerning technique, site, and equipment use. In addition to injection technique suggestions, it is argued that cold application at the injection site is effective in preventing bruising, haematoma, and pain. However, few studies have investigated the effect of cold application, particularly the effect of cold on injection pain.

Purpose—The purpose of this study was to investigate the effect of local dry cold application on the occurrence of bruising, haematoma, and pain at the injection site in LMWH injections.

Method—The patient population receiving LMWH in one hospital in Turkey formed the research population. The research involved 63 patients who had received 2 × 20 mg enoxaparine who were divided into four treatment groups. In the first group cold was not applied. Cold was applied to the injection site for 5 minutes before the injection in the second group, and for 5 minutes after the injection in the third group. In the fourth group it was applied to the injection site for 5 minutes pre- and post-injection. Following each injection the patient's pain intensity and duration were measured, and the presence of bruising and haematoma were measured at 48 and 72 hours after the injection.

Results—The results showed that a haematoma did not occur at the injection site of any subject, and there was no significant difference in the incidence or size of bruising among the groups. However, subjects' perception of pain was significantly less with ice application.

Conclusions—The study concluded that the standard injection technique can be effective both in preventing and reducing the occurrence of bruising and haematoma and in decreasing the perception and duration of injection pain. Pre-injection, pre- and post-injection, or post-injection cold application at the injection site is not effective in reducing or preventing the occurrence of bruising and haematoma. Pre-injection and pre- and post-injection cold application is effective in decreasing the duration and perception of pain. However, the authors recognise that this study needs to be repeated using a larger representative sample in order to confirm or contradict the results.

MATERNAL AND CHILD HEALTH

Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000;356:1375–83.

Abstract adapted from original.

About 3–4% of pregnancies reach term with a fetus in the breech presentation. This study compared the effectiveness of planned caesarean section with planned vaginal birth for selected breech presentation pregnancies. At 121 centres in 26 countries, 208 women with a singleton fetus in a breech presentation were randomly assigned to planned caesarean section or planned vaginal birth. Of the 1041 women assigned to planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned to planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (1.6% v 5.0%); relative risk 0.33. There were no differences between groups in terms of maternal mortality or serious maternal morbidity. The authors conclude that planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation.

Langer O, Conway DL, Berkus MD, et al. A comparison of glyburide and insulin in women with gestational diabetes mellitus. N Engl J Med 2000;343:1134–8.

Abstract adapted from original.

Women with gestational diabetes mellitus are rarely treated with a sulfonylurea drug because of concern about teratogenicity and neonatal hypoglycaemia. This study sought to explore the efficacy of these drugs in women with singleton pregnancies and gestational diabetes requiring treatment. 404 women were randomly assigned at 11–33 weeks of gestation to receive glyburide or insulin. The degree of glycaemic control and the perinatal outcomes were essentially the same for those treated with glyburide and those treated with insulin. In women with gestational diabetes, glyburide is a clinically effective alternative to insulin therapy.

Haider R, Ashworth A, Kabir I, et al. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomised controlled trial. Lancet 2000;356:1643–7.

Abstract adapted from original.

Most mothers breastfeed in Bangladesh, but they rarely practise exclusive breastfeeding. Hospital based strategies for breastfeeding promotion fail to reach them because about 95% have home deliveries. This trial sought to assess the effectiveness of trained peer counsellors offering home based support to mothers. Forty adjacent zones in Dhaka were randomised to intervention or control groups. In the intervention group 15 home based counselling visits were scheduled which included listening to mothers, learning about their difficulties, giving practical advice about breastfeeding, and giving support. A total of 363 women were enrolled in each group. Peer counselling significantly improved breastfeeding practices. For the primary outcome, the prevalence of exclusive breastfeeding at 5 months was 70% for the intervention group and 6% for the control group (difference = 64%). Mothers in the intervention group also initiated breastfeeding earlier than control mothers and were less likely to give prelacteal and postlacteal foods.

Schuh S, Teisman J, Alshehri M, et al. A comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma. N Engl J Med 2000;343:689–94.

Abstract adapted from original.

This study compared the efficacy of 2 mg inhaled fluticasone delivered by a metered dose inhaler with a valved holding chamber (spacer) with that of 2 mg/kg oral prednisone evaluated within 4 hours after administration in children 5 years or more of age being treated for severe acute asthma. The degree of improvement in pulmonary function in the initial 4 hours among those treated with prednisone was about twice that of those given fluticasone. Furthermore, the rate of hospitalisation in the fluticasone group was about three times that of the prednisone group. Children with severe acute asthma should be treated with oral prednisone and not with inhaled fluticasone or a similar inhaled corticosteroid.

Levin M, Quint PA, Goldstein B, et al, and the rBPI₂₁ Meningococcal Sepsis Study Group. Recombinant bactericidal/permeability-increasing protein (rBPI₂₁) as adjunctive treatment for children with severe meningococcal sepsis: a randomised trial. Lancet 2000;356:961–7.

Abstract adapted from original.

Endotoxin is a primary trigger of the inflammatory processes that leads to shock, multiorgan failure, and purpura fulminans in meningococcal sepsis. Bactericidal/permeability increasing protein (BPI) is a natural protein stored within the neutrophil granules that binds to and neutralises the effects of endotoxin in vitro. This trial sought to establish whether a recombinant 21 kDa modified fragment of human BPI (rBPI₂₁) would decrease death and long term disability from meningococcal sepsis in children. Children presenting in 22 centres in the UK and USA with a clinical picture suggestive of meningococcal sepsis and with evidence of severe disease were randomly assigned to rBPI₂₁ or control (human albumin solution) in addition to conventional medical therapy. The study was underpowered to detect significant differences in mortality, however fewer patients treated with rBPI₂₁ had multiple severe amputation (six of 190 (3.2%) v 15 of 203 (7.4%)), odds ratio 2.47, and more had a functional outcome similar to that before illness at day 60. The results indicate that rBPI₂₁ is beneficial in decreasing complications of meningococcal disease.

WOMEN'S HEALTH

Dimmock PW, Wyatt KT, Jones PW, et al. Efficacy of selective serotonin reuptake inhibitors in premenstrual syndrome: a systematic review. Lancet 2000;356:1131–6.

Abstract adapted from original.

Selective serotonin reuptake inhibitors (SSRIs) are increasingly being used as first line therapy for severe premenstrual syndrome (PMS). This paper reports the findings of a meta-analysis on the efficacy of SSRIs in this disorder. Fifteen randomised placebo controlled trials were included in the analysis. The primary outcome measure was a reduction in overall PMS symptoms. The pooled standardised mean difference of the effect of SSRIs on PMS strongly favoured treatment over placebo (–1.066, 95% CI –1.381 to –0.750). SSRIs were effective in treating physical and behavioural symptoms. There was no significant difference in symptom reduction between continuous and intermittent dosing or between trials funded by pharmaceutical companies and those independently funded. Withdrawal due to side effects was 2.5 times more likely in the active treatment group than in the placebo group. The authors conclude that SSRIs are an effective first line therapy for severe PMS and the side effects at low doses are generally acceptable.

Tom Smith

Research Assistant, Judge Institute of Management Studies, Cambridge University, Cambridge CB2 1AG, UK

Róisín Gallinagh

Lecturer In Nursing Research, United Hospitals and University of Ulster, School of Health Sciences, Jordanstown, Co Antrim, UK

Brendan Mccormack

Professor Of Nursing Research, Royal Hospitals Trust and University of Ulster, School of Health Sciences, Jordanstown, Co Antrim, UK

Fiona Campbell

Systematic Review Fellow, Royal College of Nursing, Radcliffe Infirmary, Oxford OX2 6HE, UK