Alternative shift models and the quality of patient care

This German paper, published in 2001 looked at one of the problems of the implementation of the working-time directive, a problem that is looming larger in the UK and Wales in particular

On 1 January 1996, the German Arbeitszeitgesetz (working-time regulation) came into effect for hospital physicians. It states that working hours must not exceed 8 hours per day, even for physician in hospitals. As a consequence, the prevalent two-shift model was legally inadmissible.

The intention of this law is to protect the physician and to create better conditions for the patients. However, a systematic evaluation of the postulated benefits was lacking.

The aim of the study was to analyze the influence of the length of daily working hours on the quality of patient care by measuring the outcome of patients in intensive care units (ICUs), comparing the two-shift model (2-SM)--two 12-h shifts--with the three-shift model (3-SM)--three 8-h shifts.

In a prospective multi-centre study, they compared the outcome of patients in six ICUs (organized by surgeons) with different models of working hours. The health status of each patient and the course on ICU were uni- and multi-variately analyzed. In addition, the technical and personnel resources of the ICUs and the hospitals were documented.

The epidemiological and the health status of patients in both groups, on admission to the ICU were comparable. Patients in the 3-SM stayed 1.6 days longer on ICU and 2.3 days longer in the hospital than the 2-SM patients. The frequency of complications, re-interventions, and readmissions to ICU was higher in the 3-SM.

The median of the APACHE-II score decreased more for 2-SM than for 3-SM patients. This means a significantly quicker recovery of the patients in 2-SM (P < 0.05). The multivariate analysis with individual outcome measures as dependent variables revealed a significant positive effect of the 2-SM on the physicians' assessment of postoperative course, on the relative frequency of therapeutic procedures, and to a lesser extent on the duration of stay in the ICU.

Ref: Langenbecks Archive Surgery March 2001

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Medical Aspects of steroid use in the gym

Steroid and other drug use in sport is an increasingly discussed topic, especially when a top athlete appears to have taken drugs. This is a précis of a paper in the Drugs and Therapeutics Bulletin. The original paper looks at all aspects of drug taking, not just steroids. 

Use of performance-enhancing drugs by athletes and bodybuilders appears to be common in the U.K. Use of performance-enhancing drugs often takes place with little knowledge or acceptance of potential harmful effects, and clinicians in many settings may see patients who are experiencing problems related to such (usually covert) use.  Here we consider medical aspects of performance-enhancing drugs.

Anabolic steroids have gained notoriety as one of the most widely used classes of performance-enhancing drugs. Surveys conducted during the 1990s suggested that, overall, around 5% of UK gym-users were using such drugs, while among people attending gyms equipped for competitive body-building, the proportion of current or previous users was around 15-50%.

When taken for several weeks, with a carefully controlled diet and exercise regimen, supra-physiological doses of testosterone (around 5-10 times the recommended replacement dose for male hypogonadism) increase fat-free body mass, muscle size and strength in healthy adult males, when compared with placebo plus diet and exercise. 

Body-builders and other gym-users sometimes use even bigger doses to increase muscle mass and strength, heighten aggression, and facilitate harder, more vigorous training.  Typically, anabolic steroids are taken in ‘cycles’ of 6-12 weeks, followed by a variable period off the drugs (from 4 weeks to several months), in order to reduce the likelihood of unwanted effects.  However, some bodybuilders take anabolic steroids virtually continuously.  Often, a mixture of sequence of oral and injected anabolic steroids is taken, in order to maximise desired effects (a practice known as ‘stacking’).  Concomitant use of other drugs to enhance performance or offset unwanted effects of steroids, or for recreation, is very common.

Anabolic steroids can cause a range of metabolic, endocrine, cardiovascular, psychological and cosmetic unwanted effects, many of which appear to be dose-related.

There is evidence that some products presented as nutritional supplements contain undeclared pharmacologically active agents, including significant amounts of anabolic steroids.

Misuse of drugs, including steroids, to improve athletic performance appears to be becoming more common, not just among athletes and bodybuilders, but also in the general population.  Schoolchildren have been targeted by dealers in some regions.  Clinicians need to be alert to the possibility that such drug use (which might not be admitted) may be the cause of a range of physical or psychological problems (including drug dependence) in their patients.  Most of the drugs and hormones currently used to enhance performance have the potential to cause severe, sometimes lethal, adverse effects.

Healthcare professionals have an important role in advising their patients about these risks and, at the least, may be able to help to minimise the likelihood of harm.

Ref: Web

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Patient Consent advice from NICE

NICE makes recommendations about whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use. NICE has now produced a leaflet about patient consent and interventional procedures.

Before a doctor, a nurse or any other health professional can treat a patient, they need the person's consent. That means they must get the patient's agreement and the patient needs to understand the likely benefits and possible risks of any treatment or procedure before agreeing to it. The Institute has produced a new leaflet to help patients who are offered procedures which NICE has said have uncertain risks and benefits.

The leaflet, called "Consent - procedures for which the benefits and risks are uncertain" is available from the NICE website at http://www.nice.org.uk/Docref.asp?d=95506. It is available in both English and in Welsh. The leaflet explains what is meant by consent, why it is necessary to give consent, what an interventional procedure is, how the NICE interventional procedures programme works and where to obtain further information.

Ref: Web

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