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Ideally, clinical prediction models are generalizable to other patient groups. Unfortunately, they perform regularly worse when validated in new patients and are then often redeveloped. While the original prediction model usually has been developed on a large data set, redevelopment then often occurs on the smaller validation set. Recently, methods to update existing prediction models with the data of new patients have been proposed. We used an existing model that preoperatively predicts the risk of severe postoperative pain (SPP) to compare five updating methods. The model was tested and updated with a set of 752 new patients (274 [36] with SPP). We studied the discrimination (ability to distinguish between patients with and without SPP) and calibration (agreement between the predicted risks and observed frequencies of SPP) of the five updated models in 283 other patients (100 [35%] with SPP). Simple recalibration methods improved the calibration to a similar extent as revision methods that made more extensive adjustments to the original model. Discrimination could not be improved by any of the methods. When the performance is poor in new patients, updating methods can be applied to adjust the model, rather than to develop a new model.

Altered respiratory rate is one of the first symptoms of medical conditions that require timely intervention, e.g., sepsis or opioid-induced respiratory depression. To facilitate continuous respiratory rate monitoring on general hospital wards a contactless, non-invasive, prototype monitor was developed using frequency modulated continuous wave radar. We aimed to study whether radar can reliably measure respiratory rate in postoperative patients. In a diagnostic cross-sectional study patients were monitored with the radar and the reference monitor (pneumotachograph during mechanical ventilation and capnography during spontaneous breathing). Eight patients were included; yielding 796 min of observation time during mechanical ventilation and 521 min during spontaneous breathing. After elimination of movement artifacts the bias and 95 % limits of agreement for mechanical ventilation and spontaneous breathing were −0.12 (−1.76 to 1.51) and −0.59 (−5.82 to 4.63) breaths per minute respectively. The radar was able to accurately measure respiratory rate in mechanically ventilated patients, but the accuracy decreased during spontaneous breathing.

Infection is a major cause of death in the intensive care unit (ICU). Strategies to reduce rates of infection in ICUs include selective digestive tract decontamination (SDD), in which cefotaxime and topical antimicrobial agents are administered for 4 days, and selective oropharyngeal decontamination (SOD), in which only topical antimicrobial agents are administered. In this cluster-randomization study involving 13 ICUs in the Netherlands, SOD and SDD did not affect crude mortality but did appear to reduce mortality slightly at day 28, with adjustment for covariates. Strategies to reduce rates of infection in ICUs include selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD). In this study involving 13 ICUs in the Netherlands, SOD and SDD did not affect crude mortality but did appear to reduce mortality slightly at day 28. Infections acquired in the intensive care unit (ICU) are important complications of the treatment of critically ill patients, increasing morbidity, mortality, and health care costs. 1 Reductions in the incidence of respiratory tract infections have been achieved with the use of prophylactic antibiotic regimens, such as selective decontamination of the digestive tract (SDD) 2 , 3 and selective oropharyngeal decontamination (SOD). 4 , 5 The SDD approach 6 , 7 consists of prevention of secondary colonization with gram-negative bacteria, Staphylococcus aureus, and yeasts through application of nonabsorbable antimicrobial agents in the oropharynx and gastrointestinal tract, preemptive treatment of possible infections with commensal respiratory tract bacteria through systemic . . .

Objective To compare the accuracy of data from hospital administration databases and a national clinical cardiac surgery database and to compare the performance of the Dutch hospital standardised mortality ratio (HSMR) method and the logistic European System for Cardiac Operative Risk Evaluation, for the purpose of benchmarking of mortality across hospitals. Methods Information on all patients undergoing cardiac surgery between 1 January 2007 and 31 December 2010 in 10 centres was extracted from The Netherlands Association for Cardio-Thoracic Surgery database and the Hospital Discharge Registry. The number of cardiac surgery interventions was compared between both databases. The European System for Cardiac Operative Risk Evaluation and hospital standardised mortality ratio models were updated in the study population and compared using the C-statistic, calibration plots and the Brier-score. Results The number of cardiac surgery interventions performed could not be assessed using the administrative database as the intervention code was incorrect in 1.4–26.3%, depending on the type of intervention. In 7.3% no intervention code was registered. The updated administrative model was inferior to the updated clinical model with respect to discrimination (c-statistic of 0.77 vs 0.85, p<0.001) and calibration (Brier Score of 2.8% vs 2.6%, p<0.001, maximum score 3.0%). Two average performing hospitals according to the clinical model became outliers when benchmarking was performed using the administrative model. Conclusions In cardiac surgery, administrative data are less suitable than clinical data for the purpose of benchmarking. The use of either administrative or clinical risk-adjustment models can affect the outlier status of hospitals. Risk-adjustment models including procedure-specific clinical risk factors are recommended.

ObjectiveTo evaluate the feasibility of a locally implemented incident-reporting procedure (IRP) in primary healthcare centres after 1 year.Setting and participantsFive primary healthcare centres caring for more than 43 000 patients in The Netherlands. GPs, medical nurses, physiotherapists, pharmacists, pharmacist assistants and trainees reported incidents (a total of 117 employees).MethodsAn IRP was implemented in which participants were encouraged to report all incidents. In addition, dedicated ‘reporting weeks’ were introduced that emphasised reporting of minor incidents and near misses. In every centre, an IRP committee analysed the reported incidents in order to initiate improvements when necessary.Outcome measuresFrequency and nature of reported incidents, number of incidents analysed by the IRP committees and number of improvements implemented. In addition, the authors studied the actual implementation of the IRP and the acceptability as experienced by participants.ResultsA total of 476 incidents were reported during a 9-month reporting period. Of all incidents, 62% were reported in a reporting week, and most were process-related. Possible harm for patients was none or small in 87% of the reported incidents. IRP committees analysed 84 incidents and found 230 root causes. All participating centres had initiated improvement projects as a result of reported incidents. Most interviewees considered the IRP feasible, but several practical, professional and personal barriers to implementation of the IRP were identified.ConclusionThe implementation of a centre-based IRP in primary care is feasible. Reporting weeks enhance the willingness to report.

Objective: To describe the association between cognitive outcome in the first postoperative week and that at three months after both off-pump and on-pump coronary bypass surgery, and to make a direct comparison of early cognitive outcome after off-pump versus on-pump surgery. Design: Randomised trial with an additional prediction study within the two randomised groups. Setting: Three centres for heart surgery in the Netherlands. Patients: 281 patients, mean age 61 years. Interventions: Participants were randomly assigned to off-pump or on-pump coronary bypass surgery. Main outcome measures: Cognitive outcome, assessed by psychologists who administered neuropsychological tests one day before and four days and three months after surgery. A logistic regression model was used to study the predictive association between early cognitive outcome, together with eight clinical variables, and cognitive outcome after three months. Results: Cognitive outcome in the first week after surgery was determined for 219 patients and was a predictor of cognitive decline after three months. This association was stronger in on-pump patients (odds ratio (OR) 5.24, p < 0.01) than in off-pump patients (OR 1.80, p  =  0.23). Early decline was present in 54 patients (49%) after off-pump surgery and 61 patients (57%) after on-pump surgery (OR 0.73, p  =  0.25). Conclusions: In patients undergoing first time coronary bypass surgery, early cognitive decline predicts cognitive outcome after three months. Early cognitive decline is not significantly influenced by the use of cardiopulmonary bypass.

BackgroundThere is an inherent tension between allowing trainees in general practice (GP) to feel comfortable to report and learn from errors in a blame-free environment while still assuring high-quality and safe patient care. Unfortunately, little is known about the types and potential severity of incidents that may confront GP trainees. Furthermore, incident reporting by resident trainees is hindered by their concern that such transparency might result in more negative performance evaluations.ObjectiveTo explore the number and nature of incidents that were reported by GP trainees and to determine whether there were differences between the reporters and non-reporters based on their performance evaluations.DesignProspective cohort study.MethodsConfidential and voluntary incident reporting was implemented in GP vocational training of the University Medical Center Utrecht, the Netherlands. Seventy-nine GP trainees were asked to report incidents over 6 months. Mixed methods were used to analyse the data.Results24 trainees reported a total of 44 incidents. 23 incidents concerned the work process and 17 concerned problems with diagnosis or therapy. Three-quarters (34/44) of incidents were determined to be not specifically related to the inexperience of the GP trainees. While actual patient harm was determined to be minimal or absent in two-thirds of incidents (29/44), the potential for moderate, major, or catastrophic harm was 89% (39/44). Trainees performing best on their performance assessment in the domain of clinical expertise reported incidents more often (43% vs 18%, p<0.03) than those who performed at a lower level.ConclusionsGP trainees rated highly by their faculty voluntarily reported incidents in the delivery of clinical care when given a safe, blame-free, and confidential reporting process. Most incidents were not found to be directly related to the inexperience of the trainee, but were caused by failing organisational processes in the healthcare delivery system. Moreover, the trainees who tended to report these incidents were those whose performance was highly evaluated in the domain of clinical expertise.

Acute gastroenteritis is common in childhood. The estimation of the degree of dehydration is essential for management of acute gastroenteritis. Plasma water was assessed as a diagnostic tool in children with acute gastroenteritis and dehydration admitted to hospital. In a prospective cohort study, 101 patients presenting at the emergency department with dehydration were included. Clinical assessment, routine laboratory tests, and plasma water measurement were performed. Plasma water was measured as a percentage of water content using dry weight method. During admission, patients were rehydrated in 12 h. Weight gain at the end of the rehydration period and 2 weeks thereafter was used to determine the percentage of weight loss as a gold standard for the severity of dehydration. Clinical assessment of dehydration was not significantly associated with the percentage of weight loss. Blood urea nitrogen ( r  = 0.3, p  = 0.03), base excess ( r  =−0.31, p  = 0.03), and serum bicarbonate ( r  = 0.32, p  = 0.02) were significantly correlated with the percentage of weight loss. Plasma water did not correlate with the percentage of weight loss. On the basis of the presented data, plasma water should not be used as a diagnostic tool in the assessment of dehydration in children with acute gastroenteritis.