- Email: [email protected]
Hospital mortality and staff workload
CORRESPONDENCE
Existing interventions implemented in more-developed countries often cannot be transferred to lessdeveloped countries. The Global Forum for Health Research is working to help correct the imbalance in health research funding from projects benefiting fewer people to projects benefiting the large majority. Andres de Francisco Global Forum for Health Research, c/o WHO, 1211 Geneva 27, Switzerland (e-mail: [email protected]) 1
2
3
Sen K, Bonita R. 2000. Global health status: two steps forward, one step back. Lancet 2000; 356: 577–82. The 10/90 Report on Health Research 2000. Global Forum for Health Research. Geneva: WHO, 2000: 156. World Health Report 1999. Geneva: WHO, 2000: 121.
megalovirus isolates resistant to ganciclovir under selective pressure during exposure to valaciclovir5 has never been formally documented. For these reasons, we suggest that for now and until valganciclovir becomes available, oral valaciclovir should be the first-choice drug for prevention of cytomegalovirus disease, at least in kidney recipients. Christophe Legendre Service de Néphrologie, Hôpital Saint-Louis, 75010 Paris, France 1
2
3
Ganciclovir-resistant cytomegalovirus Sir—Ajit P Limaye and colleagues (Aug 19, p 645)1 report the emergence of ganciclovir-resistant cytomegalovirus strains as a non-unexpected consequence of the wide use of oral ganciclovir to prevent cytomegalovirus disease in organ-transplant recipients. Ganciclovir-resistant cytomegalovirus disease occurred late in the course of transplantation and led to serious clinical complications. We do not think that the role of valaciclovir, in at least kidney transplant recipients, was clearly enough outlined as a well documented, efficient, and safe alternative to prevent cytomegalovirus disease in the discussion, nor in W Lawrence Drew’s commentary (Aug 19, p 609).2 In the original study,3 involving 306 patients who received a 90-day course of oral valaciclovir, cytomegalovirus disease that did not respond to ganciclovir was not reported and in only one patient whose death was attributed to cytomegalovirus could not be excluded. Our experience with oral valaciclovir (more than 200 kidney and kidney-pancreas recipients) agrees with the original study: we have encountered no case of ganciclovirresistant cytomegalovirus disease, which was not the case with oral ganciclovir used as a maintenance prevention.4 Moreover, antigen or PCR-guided oral or intravenous ganciclovir use has never been proven to be more or even as efficient as valaciclovir prophylaxis in a well designed trial. Finally, the theoretical possibility of emergence of cyto-
1356
4
5
Limaye AP, Corey L, Koelle DM, Davis CL, Boeckh M. Emergence of ganciclovir-resistant cytomegalovirus disease among recipients of solid-organ transplants. Lancet 2000; 356: 645–49. Drew WL. Ganciclovir resistance: a matter of time and titre. Lancet 2000; 356: 609–10. Lowance D, Neumayer HH, Legendre Ch, et al. Valacyclovir for the prevention of cytomegalovirus disease after renal transplantation. N Engl J Med 1999; 340: 1462–70. Bienvenu B, Thervet E, Bedrossian J, et al. Development of cytomegalovirus resistance to gancicovir after oral maintenance treatment in a renal transplant recipient. Transplantation 2000; 69: 182–84. Erice A. Resistance of human cytomegalovirus to antiviral drugs. Clin Microbiol Rev 1999; 12: 286–97.
Hospital mortality and staff workload Sir—W O Tarnow-Mordi and colleagues (July 15, p 185)1 relate mortality in intensive care (ICU) to high patient occupancy. They support the intuitive deductions of many clinicians but also give some possible examples of medical error identified by the Institute of Medicine in the More importantly, the USA.2 researchers show possible causes and measurable effects of nursing error. Tarnow-Mordi and co-workers concentrate appropriately on quantitative data. However, any qualitative data on concerns expressed by the nursing or medical staff about the busy, high-risk shifts is important. These data might have been available from shift reports, handover documentation, and risk-management activities, such as critical-incident and near-miss reporting by nursing or Additionally, medical staff.3 documented meetings with, or correspondence to, the clinical directors and hospital management might have helped to confirm that clinical impressions of increased risk at times of high ICU occupancy were
apparent before the data in the paper became available. Expressions of concern probably antedated confirmation of the excess mortality, as they did in the Bristol The and Winnipeg cases.3,4 involvement of medically qualified managers in the process of reporting potentially unsafe services gives them an immediate/legal responsibility for the safety of patients in that service.5 The implications of limited human or financial resources in this context have not been legally tested. Ethically, the decision must be to manage patients in the safest environment possible. Stephen Bolsin Barwon Health, Geelong Hospital, Geelong, Victoria 3220, Australia (e-mail: [email protected]) 1
2
3
4
5
Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 2000; 356: 185–89. Kohn CT, Corrigan JM, Donaldson MS. To Err is human: building a safer health system. Washington: Institute of Medicine, 1999: 1–16. Bolsin SN. Routes to quality assurance. International Journal for Quality in Healthcare 2000; 12 (5): accepted for publication. Sibbald B. Twelve deaths in Winnipeg: judge must ponder 48 000 pages of testimony. Can Med Assoc J 1998; 159 (10): 1285–87. Roylance v General Medical Council. London: 3 WLR, 1999: 541.
Sir—W O Tarnow-Mordi and colleagues’ report1 is a warning for politicians and administrators of public-health-care funding. As suspected by several physicians working in public hospitals, excessive workload for health carers in ICUs is accompanied by increased mortality. Similarly, M C Blunt and K R Burchet demonstrate that the lack of 24 h availability of specialists in ICUs is also associated with increased mortality.2 Patients who present to accident and emergency departments could be also put at increased risk when nursing or medical workload is high because of potential increments in iatrogenic complications, human errors, or both, decreased supervision, or excessive delays in medical assistance or drug administration. We suggest that overcrowding in accident and emergency departments leads to a decline in the quality of health care, shown by mortality.3 We gathered weekly data on deaths in the internal medicine unit (IMU) of our accident and emergency department for 200 consecutive weeks
THE LANCET • Vol 356 • October 14, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
CORRESPONDENCE
Mortality (%)
1·5
p=0·04
HIV/AIDS epidemiology
1·0 0·5
Hi gh
M od er at e In te rm ed ia te
0
Workload 2·0
Mortality (%)
1·5
1·0
p=0·01 r=0·18
0·5
95 0
90 0
85 0
80 0
75 0
70 0
65 0
60 0
55 0
0
Number of weekly visits Association between number of visits to accident and emergency department and death Weeks stratified workload: moderate is <700 visits; intermediate is 701–800 visits; high is >800 visits.
(from August, 1995, to June, 1999).4 The staff, organisation of the department and hospital, the area of coverage, and health-care resources remained essentially unchanged during that period, and, therefore we estimated staff workload by weekly number of visits to the IMU. To minimise bias because of factors unrelated to intervention, we included only patients who arrived alive (we excluded those who arrived in cardiopulmonary arrest with unsuccessful resuscitation manoeuvres) and patients who died in the first 24 h after arrival (we excluded patients who remained in the department for longer periods because of lack of beds in general wards). Increase in staff workload in our IMU was associated with an increase in mortality (figure). Periods of high demand in the accident and emergency department could lead to slowness in admission to general hospital wards and contribute to increased mortality. Additionally in some periods of high patient affluence to this department, (such as winter) there is also a higher frequency of more aggressive illnesses, exacerbations of chronic diseases, or both. Whatever the cause, Tarnow-Mordi
THE LANCET • Vol 356 • October 14, 2000
and colleagues’ study and our data seem to show that staff workload must be lessened to improve the quality of health care. Whether to address the need for available resources or other imperative medical issues is a difficult decision but, in any case, staff workload implies not only apparent innocuous disorganisation in medical processes, but also entails objective adverse consequences for the population. *Òscar Miró, Miquel Sánchez, José Millá Emergency Department, Hospital Clinic, 08036 Barcelona, Catalonia, Spain (e-mail: [email protected]) 1
2
3
4
Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 2000; 356: 185–89. Blunt MC, Burchett KR. Out-of-hours consultant cover and case-mix-adjusted mortality in intensive care. Lancet 2000; 356: 735–36. Miró O, Antonio MT, Jiménez S, et al. Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med 1999; 6: 105–07. Miró O, Jiménez S, Alsina C, et al. Revisitas no programadas en un servicio de urgencias medicina hospitalario: incidencia y factores implicados. Med Clin (Barc) 1999; 112: 610–15.
Sir—The report of Evan Wood and colleagues (June 17, p 2096)1 illustrates the dangers of taking a narrow medical view of the HIV/AIDS epidemic in Africa. It is inherently obvious that widespread provision of antiretroviral therapy would have an impact on life expectancy, all else being equal (which of course it isn’t). A more helpful approach would be to compare the impact of such levels of expenditure on meeting basic health needs and eradicating poverty. Wood and colleagues admit that they do not take into account the costs of the extra human resources and infrastructure required to provide antiretrovirals, but to consider the immediate drug costs alone is totally unrealistic, even for effective prevention of mother-to-child transmission. The investigators should also consider the overall economic cost to a country of the huge economic outflows of expenditure on antiretrovirals, which would represent a further massive drain of wealth from the South to the North. Finally, the title of the paper is very misleading, implying that the focus of the modelling was sub-Saharan Africa as a whole, when it was in fact South Africa alone. South Africa’s gross domestic product per person is much higher than that of nearly all other sub-Saharan African countries, and health expenditure is 10–20 times greater. Wood and colleagues’ paper runs the risk of reversing the growing realisation that the HIV/AIDS epidemic in southern Africa is a broad social, cultural, political, and economic issue, rather than a purely medical one. I urge more circumspection in future before rushing papers such as this into print and giving them such prominence. Charles Todd Delegation of the European Commission in Zimbabwe, PO Box 4252, Harare, Zimbabwe (e-mail: [email protected]) 1
Wood E, Braitstein P, Montaner JSG, et al. Extent to which low-level use of antiretroviral treatment could curb the AIDS epidemic in sub-Saharan Africa. Lancet 2000; 355: 2095–100.
Authors’ reply Sir—We acknowledge that AIDS in Africa is a complex problem, and that a widespread campaign which addresses education, poverty, and social issues is required to substantially curb the
1357
For personal use only. Not to be reproduced without permission of The Lancet.
Existing interventions implemented in more-developed countries often cannot be transferred to lessdeveloped countries. The Global Forum for Health Research is working to help correct the imbalance in health research funding from projects benefiting fewer people to projects benefiting the large majority. Andres de Francisco Global Forum for Health Research, c/o WHO, 1211 Geneva 27, Switzerland (e-mail: [email protected]) 1
2
3
Sen K, Bonita R. 2000. Global health status: two steps forward, one step back. Lancet 2000; 356: 577–82. The 10/90 Report on Health Research 2000. Global Forum for Health Research. Geneva: WHO, 2000: 156. World Health Report 1999. Geneva: WHO, 2000: 121.
megalovirus isolates resistant to ganciclovir under selective pressure during exposure to valaciclovir5 has never been formally documented. For these reasons, we suggest that for now and until valganciclovir becomes available, oral valaciclovir should be the first-choice drug for prevention of cytomegalovirus disease, at least in kidney recipients. Christophe Legendre Service de Néphrologie, Hôpital Saint-Louis, 75010 Paris, France 1
2
3
Ganciclovir-resistant cytomegalovirus Sir—Ajit P Limaye and colleagues (Aug 19, p 645)1 report the emergence of ganciclovir-resistant cytomegalovirus strains as a non-unexpected consequence of the wide use of oral ganciclovir to prevent cytomegalovirus disease in organ-transplant recipients. Ganciclovir-resistant cytomegalovirus disease occurred late in the course of transplantation and led to serious clinical complications. We do not think that the role of valaciclovir, in at least kidney transplant recipients, was clearly enough outlined as a well documented, efficient, and safe alternative to prevent cytomegalovirus disease in the discussion, nor in W Lawrence Drew’s commentary (Aug 19, p 609).2 In the original study,3 involving 306 patients who received a 90-day course of oral valaciclovir, cytomegalovirus disease that did not respond to ganciclovir was not reported and in only one patient whose death was attributed to cytomegalovirus could not be excluded. Our experience with oral valaciclovir (more than 200 kidney and kidney-pancreas recipients) agrees with the original study: we have encountered no case of ganciclovirresistant cytomegalovirus disease, which was not the case with oral ganciclovir used as a maintenance prevention.4 Moreover, antigen or PCR-guided oral or intravenous ganciclovir use has never been proven to be more or even as efficient as valaciclovir prophylaxis in a well designed trial. Finally, the theoretical possibility of emergence of cyto-
1356
4
5
Limaye AP, Corey L, Koelle DM, Davis CL, Boeckh M. Emergence of ganciclovir-resistant cytomegalovirus disease among recipients of solid-organ transplants. Lancet 2000; 356: 645–49. Drew WL. Ganciclovir resistance: a matter of time and titre. Lancet 2000; 356: 609–10. Lowance D, Neumayer HH, Legendre Ch, et al. Valacyclovir for the prevention of cytomegalovirus disease after renal transplantation. N Engl J Med 1999; 340: 1462–70. Bienvenu B, Thervet E, Bedrossian J, et al. Development of cytomegalovirus resistance to gancicovir after oral maintenance treatment in a renal transplant recipient. Transplantation 2000; 69: 182–84. Erice A. Resistance of human cytomegalovirus to antiviral drugs. Clin Microbiol Rev 1999; 12: 286–97.
Hospital mortality and staff workload Sir—W O Tarnow-Mordi and colleagues (July 15, p 185)1 relate mortality in intensive care (ICU) to high patient occupancy. They support the intuitive deductions of many clinicians but also give some possible examples of medical error identified by the Institute of Medicine in the More importantly, the USA.2 researchers show possible causes and measurable effects of nursing error. Tarnow-Mordi and co-workers concentrate appropriately on quantitative data. However, any qualitative data on concerns expressed by the nursing or medical staff about the busy, high-risk shifts is important. These data might have been available from shift reports, handover documentation, and risk-management activities, such as critical-incident and near-miss reporting by nursing or Additionally, medical staff.3 documented meetings with, or correspondence to, the clinical directors and hospital management might have helped to confirm that clinical impressions of increased risk at times of high ICU occupancy were
apparent before the data in the paper became available. Expressions of concern probably antedated confirmation of the excess mortality, as they did in the Bristol The and Winnipeg cases.3,4 involvement of medically qualified managers in the process of reporting potentially unsafe services gives them an immediate/legal responsibility for the safety of patients in that service.5 The implications of limited human or financial resources in this context have not been legally tested. Ethically, the decision must be to manage patients in the safest environment possible. Stephen Bolsin Barwon Health, Geelong Hospital, Geelong, Victoria 3220, Australia (e-mail: [email protected]) 1
2
3
4
5
Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 2000; 356: 185–89. Kohn CT, Corrigan JM, Donaldson MS. To Err is human: building a safer health system. Washington: Institute of Medicine, 1999: 1–16. Bolsin SN. Routes to quality assurance. International Journal for Quality in Healthcare 2000; 12 (5): accepted for publication. Sibbald B. Twelve deaths in Winnipeg: judge must ponder 48 000 pages of testimony. Can Med Assoc J 1998; 159 (10): 1285–87. Roylance v General Medical Council. London: 3 WLR, 1999: 541.
Sir—W O Tarnow-Mordi and colleagues’ report1 is a warning for politicians and administrators of public-health-care funding. As suspected by several physicians working in public hospitals, excessive workload for health carers in ICUs is accompanied by increased mortality. Similarly, M C Blunt and K R Burchet demonstrate that the lack of 24 h availability of specialists in ICUs is also associated with increased mortality.2 Patients who present to accident and emergency departments could be also put at increased risk when nursing or medical workload is high because of potential increments in iatrogenic complications, human errors, or both, decreased supervision, or excessive delays in medical assistance or drug administration. We suggest that overcrowding in accident and emergency departments leads to a decline in the quality of health care, shown by mortality.3 We gathered weekly data on deaths in the internal medicine unit (IMU) of our accident and emergency department for 200 consecutive weeks
THE LANCET • Vol 356 • October 14, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
CORRESPONDENCE
Mortality (%)
1·5
p=0·04
HIV/AIDS epidemiology
1·0 0·5
Hi gh
M od er at e In te rm ed ia te
0
Workload 2·0
Mortality (%)
1·5
1·0
p=0·01 r=0·18
0·5
95 0
90 0
85 0
80 0
75 0
70 0
65 0
60 0
55 0
0
Number of weekly visits Association between number of visits to accident and emergency department and death Weeks stratified workload: moderate is <700 visits; intermediate is 701–800 visits; high is >800 visits.
(from August, 1995, to June, 1999).4 The staff, organisation of the department and hospital, the area of coverage, and health-care resources remained essentially unchanged during that period, and, therefore we estimated staff workload by weekly number of visits to the IMU. To minimise bias because of factors unrelated to intervention, we included only patients who arrived alive (we excluded those who arrived in cardiopulmonary arrest with unsuccessful resuscitation manoeuvres) and patients who died in the first 24 h after arrival (we excluded patients who remained in the department for longer periods because of lack of beds in general wards). Increase in staff workload in our IMU was associated with an increase in mortality (figure). Periods of high demand in the accident and emergency department could lead to slowness in admission to general hospital wards and contribute to increased mortality. Additionally in some periods of high patient affluence to this department, (such as winter) there is also a higher frequency of more aggressive illnesses, exacerbations of chronic diseases, or both. Whatever the cause, Tarnow-Mordi
THE LANCET • Vol 356 • October 14, 2000
and colleagues’ study and our data seem to show that staff workload must be lessened to improve the quality of health care. Whether to address the need for available resources or other imperative medical issues is a difficult decision but, in any case, staff workload implies not only apparent innocuous disorganisation in medical processes, but also entails objective adverse consequences for the population. *Òscar Miró, Miquel Sánchez, José Millá Emergency Department, Hospital Clinic, 08036 Barcelona, Catalonia, Spain (e-mail: [email protected]) 1
2
3
4
Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 2000; 356: 185–89. Blunt MC, Burchett KR. Out-of-hours consultant cover and case-mix-adjusted mortality in intensive care. Lancet 2000; 356: 735–36. Miró O, Antonio MT, Jiménez S, et al. Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med 1999; 6: 105–07. Miró O, Jiménez S, Alsina C, et al. Revisitas no programadas en un servicio de urgencias medicina hospitalario: incidencia y factores implicados. Med Clin (Barc) 1999; 112: 610–15.
Sir—The report of Evan Wood and colleagues (June 17, p 2096)1 illustrates the dangers of taking a narrow medical view of the HIV/AIDS epidemic in Africa. It is inherently obvious that widespread provision of antiretroviral therapy would have an impact on life expectancy, all else being equal (which of course it isn’t). A more helpful approach would be to compare the impact of such levels of expenditure on meeting basic health needs and eradicating poverty. Wood and colleagues admit that they do not take into account the costs of the extra human resources and infrastructure required to provide antiretrovirals, but to consider the immediate drug costs alone is totally unrealistic, even for effective prevention of mother-to-child transmission. The investigators should also consider the overall economic cost to a country of the huge economic outflows of expenditure on antiretrovirals, which would represent a further massive drain of wealth from the South to the North. Finally, the title of the paper is very misleading, implying that the focus of the modelling was sub-Saharan Africa as a whole, when it was in fact South Africa alone. South Africa’s gross domestic product per person is much higher than that of nearly all other sub-Saharan African countries, and health expenditure is 10–20 times greater. Wood and colleagues’ paper runs the risk of reversing the growing realisation that the HIV/AIDS epidemic in southern Africa is a broad social, cultural, political, and economic issue, rather than a purely medical one. I urge more circumspection in future before rushing papers such as this into print and giving them such prominence. Charles Todd Delegation of the European Commission in Zimbabwe, PO Box 4252, Harare, Zimbabwe (e-mail: [email protected]) 1
Wood E, Braitstein P, Montaner JSG, et al. Extent to which low-level use of antiretroviral treatment could curb the AIDS epidemic in sub-Saharan Africa. Lancet 2000; 355: 2095–100.
Authors’ reply Sir—We acknowledge that AIDS in Africa is a complex problem, and that a widespread campaign which addresses education, poverty, and social issues is required to substantially curb the
1357
For personal use only. Not to be reproduced without permission of The Lancet.