The association between first-time accreditation and the delivery of recommended care: a before and after study in the Faroe Islands

Background Significant resources are spent on hospital accreditation worldwide. However, documentation of the effects of accreditation on processes, quality of care and outcomes in healthcare remain scarce. This study aimed to examine changes in the delivery of patient care in accordance with clinical guidelines (recommended care) after first-time accreditation in a care setting not previously exposed to systematic quality improvement initiatives. Methods We conducted a before and after study based on medical record reviews in connection with introducing first-time accreditation. We included patients with stroke/transient ischemic attack, bleeding gastric ulcer, diabetes, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture treated at public, non-psychiatric Faroese hospitals during 2012–2013 (before accreditation) or 2017–2018 (after accreditation). The intervention was the implementation of a modified second version of The Danish Healthcare Quality Program (DDKM) from 2014 to 2016 including an on-site accreditation survey in the Faroese hospitals. Recommended care was assessed using 63 disease specific patient level process performance measures in seven clinical conditions. We calculated the fulfillment and changes in the opportunity-based composite score and the all-or-none score. Results We included 867 patient pathways (536 before and 331 after). After accreditation, the total opportunity-based composite score was marginally higher though the change did not reach statistical significance (adjusted percentage point difference (%): 4.4%; 95% CI: − 0.7 to 9.6). At disease level, patients with stroke/transient ischemic attack, bleeding gastric ulcer, COPD and childbirth received a higher proportion of recommended care after accreditation. No difference was found for heart failure and diabetes. Hip fracture received less recommended care after accreditation. The total all-or-none score, which is the probability of a patient receiving all recommended care, was significantly higher after accreditation (adjusted relative risk (RR): 2.32; 95% CI: 2.03 to 2.67). The improvement was particularly strong for patients with COPD (RR: 16.22; 95% CI: 14.54 to 18.10). Conclusion Hospitals were in general more likely to provide recommended care after first-time accreditation.

Bleeding gastric ulcer from a pulmonary artery 20 years post-oesophagectomy: a common presentation with a rare cause

This case presents an unusually late complication of oesophagectomy 20-years post-surgery, with upper gastrointestinal bleeding. Further investigation revealed a gastric conduit ulcer eroding into the lower lobe of the right lung, forming a fistula with a basal branch of the right pulmonary artery. Upon successful embolisation, the HydroCoil® was visible on endoscopy. This case highlights the need for lifetime proton pump inhibitor cover post-oesophagectomy and demonstrates that when approaching uncommon presentations of common problems, careful consideration to treatment technique is essential.

THE EFFICACY OF RECOMBINANT INTERLEUKIN-1Β IN SURGICAL TREATMENT OF ACUTE ULCERATIVE GASTRODUODENAL BLEEDINGS

There was reported the results of the use of recombinant interleukin-1β in basic conservative measures in the surgical treatment of acute gastroduodenal ulcer bleeding. Gastric ulcer were in 20 patients, duodenal ulcer in 84 patients and combined ulcers in 16 patients. According to А.А. Шалимов hospitalized patients with mild blood loss were 27, moderate degree - 62 and severe degree - 31 patients. According to J. Forrest, 29 showed active bleeding (F Ia, F Ib), in 67 - unstable hemostasis (F IIa, F IIb, F IIc) and in 24 - F III. Within the framework of differentiated individual-active tactics, patients were operated in emergency (21), urgent (38), delayed (35), and 26 people underwent early planned operations. Patients in the main group (63) after the operation, was included recombinant interleukin-1β to the basic therapeutic measures additionally, taking into account the degree of blood loss and immune disorders. Patients of comparison group (57) before and after surgery received standard basic therapy without immunocorrection. In a comparative aspect, it has been proved that in postoperative period on the background of standard conservative measures, the use of recombinant interleukin-1β positively influences elimination of the secondary immunodeficiency and cytokine imbalance significantly improves the results of surgical treatment.

ESTIMATION OF RISK FACTORS OF EARLY POSTOPERATIVE MORTALITY IN ELDERLY PATIENTS WHO ARE SUBJECTED TO GASTRIC SURGICAL PROCEDURES

The use of screening programms in elderly population (age ≥65 years) comprises an increasing proportion of patients undergoing emergency general surgery (EGS) procedures nowadays. The aim was to determine the intra-hospital mortality rate in elderly patients undergoing gastric surgical procedures. 108 elderly patients (≥65 years old) were examined, divided into two groups: deceased and surviving surgical patients, treated for diseases (benign and malignant) of the stomach. The patients were divided into four age groups and five ASA groups, taking into account the presence of chronic diseases, the values of some laboratory parameters, administered transfusion and the occurrence of surgical complications during hospitalization. The mortality rate among elderly patients was 28.7%. The significant risk factors for mortality were: emergency surgery (p < 0.001), bleeding gastric ulcer operations (p = 0.042), lung (p = 0.003), kidney (p < 0.001), heart (p = 0.025) diseases, ASA score of 4 or higher (p < 0.001), serum levels (higher after two times measurement) of creatinine, haemoglobin, CRP, PCT and glycemia (p < 0.001). In order to improve medical treatment, the determination of independent validated risk indicators for mortality in elderly patients might lead to developing a dedicated scoring system.

Rupture of Hepatocellular Carcinoma after Transarterial Chemoembolization followed by Massive Gastric Bleeding

Introduction. Transarterial chemoembolization (TACE) is the first-line therapy for patient with unresectable hepatocellular carcinoma (HCC). Although TACE is a generally safe procedure, major complications can be occurred. We describe a patient with rupture of HCC after TACE followed by gastric bleeding. Case Presentation. An 81-year-old man presented with worsening epigastric pain. He had been diagnosed with multiple HCC with nonalcoholic steatohepatitis and underwent TACE 19 days previously. A contrast enhanced computed tomography (CT) scan of the abdomen showed rupture of an HCC. He was treated nonoperatively and discharged on hospital day 18. Five weeks after TACE, he was emergently admitted with massive hematochezia and shock. A contrast enhanced CT scan demonstrated extrinsic gastric compression by an HCC lesion with extravasation of contrast into the stomach. Emergent upper gastrointestinal endoscopy showed a bleeding gastric ulcer with extraluminal compression which was successfully controlled by hypertonic saline-epinephrine injection. Due to tumor progression, he was discharged for palliative care and died six weeks after TACE. Conclusion. Rupture of HCC is a life-threatening complication after TACE with mortality rates up to 50%. After treatment of a ruptured HCC, extragastric compression and bleeding can occur due to direct compression by a primary lesion or intraperitoneal dissemination.

An Incidental Finding of AL‑associated Amyloidosis Presenting as Gastric Ulcers

ABSTRACTGastrointestinal tract amyloidosis has been reported in rare instances and related symptoms are usually nonspecific to the disease process. We present a patient who initially had melena on anticoagulation and endoscopy revealed a bleeding gastric ulcer. Hemostasis was achieved. The patient had a recurrence of symptoms despite being off anticoagulation months later and at that time repeat endoscopy showed multiple gastric ulcers with surrounding friable mucosa. Biopsy results were significant for light chain associated‑amyloidosis. This case represents a rare cause of gastric ulcer.