Quality and Safety in Health Care最新文献

{"title":"008 Evaluation of the efficacy of a care network for secondary prevention stroke","authors":"Y. Ejot, F. Raffe, V. Osseby-Guy, D. Touze, A. Peyron, F. Pelisser, P. Routhier, M. Giroud","doi":"10.1136/QSHC.2010.041608.2","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041608.2","url":null,"abstract":"Context and Aims Secondary prevention of stroke is a major medical challenge because recurrence is a cause of motor handicap and dementia. The prevention strategy lies on two effective and validated measures: identification of the risk factors of recurrence and the specific treatment of these risk factors. Nevertheless, there is a mismatch between the data of positive clinical trials conducted in highly selected populations and the results observed in real life from nonselected populations. On the basis of this observation, the neurologists of Burgundy have set up a care network, called Réseau Bourgogne–AVC, whose aims were to decrease the incidence of stroke recurrence, using national and international recommendations. Program and Methods The Réseau Bourgogne—AVC was set up with the label of Unions Régionales des Caisses d'Assurance Maladie (URCAM) and Appalachian Regional Healthcare (ARH) in 2003 to coordinate and standardize the secondary prevention of stroke in the region. The evaluation was based on the population of the city of Dijon (150 000 inhabitants) thanks to the Dijon Stroke Registry which collects close to 220 strokes every year. Data have been gathered continuously since 1985. Data on recurrent strokes from 1985 to 2002 allowed us to calculate a model of the trends using a Poisson Logistic regression, considering the age, sex and year as continuous variables. The curve of the recurrent strokes observed from 2003 to 2007 was compared to the curve of expected recurrent stroke. Results During the period 2003–2007, we collected 162 recurrent strokes (14.8% of the cases) compared to 196 expected recurrent strokes (18.0% of the cases), with a significant decrease (0.82 (0.70-0.96)) (p=0.013). Discussion The significant decrease in the number of strokes collected since 2003 compared to the expected number, is a new and encouraging trend with regard to the actions conducted by the network. The first explanation for the decrease in the number of recurrent strokes could be the decrease in the incidence rates of stroke in Dijon. However, in Dijon, the incidence rate has been stable since 1985. Another explanation could be the decrease in the mortality rates observed in Dijon. However, an increase in the number of patients surviving strokes would increase the number of recurrent strokes because of the increased number of the population at risk of recurrence. The use of new therapies could also explain this trend. But between 2003 and 2007, there were no new therapies, apart from statins, which were validated at the end of our study. The probable explanation is the effect of the stroke network. The network could act by spreading awareness of good practices, appropriate treatments and the relevant indications, encouraging better compliance of patients, better coordination in secondary prevention, decompartmentalisation of medical services, and the development of follow-up at home to provide patients with therapeutic education and thus allow t","PeriodicalId":20849,"journal":{"name":"Quality and Safety in Health Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81334536","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"010 An example of evaluation of the professional practice leading to the improvement of care: the hospital stroke network","authors":"G. Osseby, Y. Béjot, A. Chantegret, J. Durier, D. Honnart, H. Roy, F. Ricolfi, J. Gerbet, A. Bernard, T. Moreau, M. Giroud, M. Freysz","doi":"10.1136/QSHC.2010.041616.10","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041616.10","url":null,"abstract":"Context The management of acute stroke has become a structuring model in hospital organisation with the aim to improve the acute care of stroke. Stroke has become a medical emergency since the arrival of new active treatments in cerebral infarction. Fibrinolysis, for example, needs to be administered within the first 3 hours following admission to a stroke unit. The fact that stroke is a race against time is a new reality for carers. In contrast, the consequences of a poorly organised network may be severe. If fibrinolysis were used in all of the eligible cases of cerebral infarction, we could avoid 7500 deaths or severe handicap in France every year. Objectives What triggered our interest in setting up the Professional Practice Evaluation (PPE) was the realisation in 2006 that in Dijon University Hospital only a small number of interventions involved fibrinolysis (a mean of 12 per year). The principal aim of the PPE was to identify the intrahospital factors that led to delay in admission to the Stroke Unit at Dijon CHU, while the secondary objective was to increase the use of fibrinolysis every year. Methods All of those involved in the stroke network were trained according to a standardised protocol from 01 January 2006 to 30 September 2006: Staff working in the emergency room, imaging services, biology laboratory, ambulance and transportation services and stroke unit. The indicators, which were compared before and after the PPE, were the following: the delay to imaging, to biological results, to arrival at the stroke unit and the number of fibrinolysis. This prospective work was performed from 01 January 2006 to 30 September 2006, and was evaluated in 2007, and the data were compared to prior data collected since 1985 by the Dijon Stroke Registry. Results We observed the following results: the proportion of imaging performed within the first 3 hours rose from 46% to 83 %; the mean delay to imaging decreased from156 min to 115 min, the time from arrival to imaging dropped from 87 to 37 min; the time between arrival and biological results decreased from 70 to 32 min; the mean annual number of fibrinolyses performed, around 12 per year between 2003 to 2006, tripled in 2007 and by 6 in 2008. Discussion The training of the different professionals dramatically improved all the parameters evaluated, leading to a huge increase in the number of fibrinolyses, and inestimable benefits for stroke patients. Moreover, all the services that were considered unsatisfactory, such as imaging, biological analyses and ambulance, reacted positively, which made it possible to improve the parameters. We found that carers were willing to revise their usual practices without a feeling of guilt, and thus generated a huge improvement in the whole care process. Perspectives We are evaluating the benefits in terms of the decrease in mortality and handicap since the implementation of PPE. Conclusion We have demonstrated that at no extra cost it is possible to improve a stro","PeriodicalId":20849,"journal":{"name":"Quality and Safety in Health Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81390677","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"246 Effects of a multifaceted intervention on the cardiovascular risk factors of high-risk hypertensive patients in primary prevention (ESCAPE trial)","authors":"D. Pouchain, D Huas, J. Lebeau, V. Renard, P. Druais","doi":"10.1136/QSHC.2010.041616.11","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041616.11","url":null,"abstract":"Program ESCAPE is a cluster randomised controlled trial designed to show that a multifaceted intervention, aimed at general practitioners (GPs), can improve high-risk hypertensive patients' health outcomes, without affecting their quality of life. 12 regional colleges of GP, including 128 investigators, were randomised as clusters in the intervention group (IG), and 11 colleges, including 131 GP, in the control group (CG). 1832 hypertensive patients with at least two other cardiovascular risk factors, including 1047 patients suffering from type 2 diabetes (T2D), all in primary prevention, were included between November 2006 and July 2007, and then followed-up for 2 years. The intervention consisted of: One day of medical education, aiming on the therapeutic targets and strategies for achievement, featured in the HAS and AFSSAPS guidelines on hypertensive and T2D patients' care, An electronic blood pressure (BP) measurement device, and a leaflet summarising the guidelines provided to the GP, five prevention-dedicated consultations, of 30 min each, twice a year, performed by the GP. During these, the GP was to negotiate drug changes if guidelines targets were not achieved, and systematically assessed patient's compliance, dietetics, exercise and smoking issue if needed, A feedback on IG patients' results at baseline and at 1-year follow-up. Primary end point is the number of patients achieving all the targets featured in the guidelines, namely: BP≤140/90 mm Hg, LDL-C≤1.30 g/l, and no smoking, for the hypertensive patients without T2D. BP≤130/80 mm Hg, LDL-C≤1.0 g/l, HbA1c≤7%, a low-dose of aspirin, and no smoking, for the hypertensive patients with T2D. Secondary end points are: the number of patients achieving each goal, the variation of the value of each goal, clinical cardiovascular events (angina pectoris, acute coronary syndrome, myocardial infarction, stroke, heart failure, arteritis, cardiovascular death, and death from any other cause) and the quality of life (SF-8). Results From 1832 patients included (905 in the IG and 927 in the CG), 1 741 (95%) completed the study. The database will be closed in December 2009. The final results will be available in January 2010, and the comparison between the IG and the CG, in terms of clinical outcomes, will be presented at the HAS and BMJ symposium. The baseline characteristics of the 1832 patients were: Male 63.5%, mean age 61 year, mean body weight=85.9 kg, BMI=30.9 kg/m2, BP=142/82 mm Hg, LDL-C=1.2 g/l, fasting blood glucose=1.2 g/l, mean HbA1c=7.0%. BP targets was achieved for 25.2% of the patients, LDL-C targets for 40.5%, HbA1c target for 54.7% of the T2D patients, 30.2% of them received aspirin, and 78.2% were non smokers. On the primary end point: 7.2% of the 1832 patients achieved their 3 or 5 targets. 11.0% of the 785 hypertensive without T2D patients achieved their three targets. 1.7 % of 1 047 T2D patients achieved their five targets. Conclusion ESCAPE population's baseline characteristics","PeriodicalId":20849,"journal":{"name":"Quality and Safety in Health Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82119056","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"092 Long-term impact of cardiovascular therapy intensification after postoperative myocardial necrosis following major vascular surgery: a case control study","authors":"P. Coriat, Y. Le Manach, A. Foucrier, J. Goarin, M. Fléron","doi":"10.1136/qshc.2010.041632.13","DOIUrl":"https://doi.org/10.1136/qshc.2010.041632.13","url":null,"abstract":"Background and Objectives Postoperative acute cardiac events are one of the most common causes of mortality following vascular surgery. The repercussions of myocardial infarction (MI) exacerbate immediate postoperative mortality and seriously impact on life expectancy. Postoperative surveillance to detect elevated troponin I (cTnI) levels (the most accurate cardiac biomarker for postoperative MI) is not only crucial to early diagnosis of postoperative MI but can also help limit long-term mortality by prompting appropriate treatment. However, the impact of such treatment on short- and long-term postoperative morbidity and mortality has not been studied. Management might be suboptimal. Our objective was to analyse the immediate and longer term (1 year) impact of following recommendations based on evidence-based data by intensifying treatment of coronary artery disease in patients presenting elevated postoperative cardiac cTnI levels following major vascular surgery. Programme We undertook a retrospective case-controlled study on a population of 665 consecutive patients who had undergone vascular surgery. The case subjects were the 66 patients (9.9%) with elevated postoperative cTnI. For each case, we selected 2 controls from the remaining patients using logistic regression and nearest neighbour matching methods applied to preoperative and intra-operative sets of variables Results According to an independent expert committee, 44 (67%) of the 66 patients had received treatment intensification. Mean follow-up was 14 months (range, 6–31). Intensified postoperative cardiovascular treatment was associated with significant benefit in terms of 1-year mortality (p=0.027) on comparing patients who had or had not received intensified treatment. There was no difference in mortality between patients receiving intensified postoperative therapy and those who did not experience a postoperative elevation in cTn1, suggesting that treatment might normalise life expectancy in patients with elevated cTnI. In over 70% of patients, the treatment taken at 1 year on a regular basis was no different from the treatment they had been given on discharge from hospital. Discussion and Conclusion In patients with elevated postoperative cTnI, short- and long-term outcomes can be improved by following evidence-based recommendations for the management of acute coronary syndromes. In addition, appropriate secondary prevention of coronary artery disease following hospital discharge contributes towards a positive impact on life expectancy in these patients. Contexte et objectifs L'insuffisance coronaire aiguë reste l'une des principales causes de morbidité et de mortalité chez les opérés de chirurgie vasculaire. Cette complication aggrave le risque postopératoire immédiat et altère de façon importante l'espérance de vie à moyen terme des opérés. La mise en évidence d'une élévation de troponine (TnI) post opératoire qui détecte avec fiabilité une insuffisance coronair","PeriodicalId":20849,"journal":{"name":"Quality and Safety in Health Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78970536","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"069 Lifestyle project for patients with Alzheimer's disease in highly sheltered accommodation within a residential home","authors":"Reckmans Caroline","doi":"10.1136/QSHC.2010.041624.74","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.74","url":null,"abstract":"Background and objectives Between 1998 and 2006, the St Vincent residential home for elderly dependent people (EHPAD) welcomed both residents without cognitive impairment and residents with Alzheimer's disease. We identified four main types of problem: quarrels, runaways, falls, and depressive syndrome. These incited us to set up a ‘Lifestyle project’ within a sheltered area welcoming Alzheimer patients. Its main objective was to offer patients a material and human space that was reassuring and friendly and that would help them maintain their residual abilities and enjoyment of life. The focus was on daily living activities, different types of pastime, entertainment, and encouraging self-expression. Program In October 2007, we created the ‘CANTOU’, a homely house within the St Vincent residential home, with accommodation suitable for 16 Alzheimer patients. Patients in this sheltered area have a Mini-Mental score (MMS) of 3-10/30 and suffer from excessive wandering. The team care includes three house matrons during the day and one at night. Management is tailored to each patient. The main objective of our program is to fight depression by early detection of: Eating disorders: We fight lack of appetite by a culinary project linked to ‘work’ in a vegetable garden. We monitor weight loss weekly and use high-protein food supplements when needed. Anxiety and agitation: We propose a pastime based on social life in order to widen links with the ‘outside world’ and enhance relationships with the family. We help prevent falls by using ‘Alzheimer's beds’ that can be lowered right down to the ground. Loss of self-esteem: We offer a pastime based on daily living which aims to raise the patient's self-esteem and maintain functional abilities, without inducing any frustration. There is great flexibility in all our activities and relationships. Their aim is to maintain the patient's self-esteem, encourage use of residual abilities, support procedural memory, and in particular help patients enjoy life. Results After 2 years, we have observed an improvement in several aspects of the residents' quality of life: (i) We have not observed any weight loss, rather the contrary, (ii) We have never had any need to use neuroleptics or anxiolytic drugs, unlike in retirement homes where they are in routine use, (iii) Residual functions have been maintained. The MMS is stable in three CANTOU residents whereas three residents in the main establishment are now bedridden. Project limitations Once the patient no longer reacts to stimuli, he or she is transferred to the main establishment. Looking ahead To apply the same lifestyle project in a daycare setting for a greater number of patients. Conclusion High-quality nursing care for Alzheimer's patients helps maintain their residual capacities. Objectif(s), contexte Entre 1998 et 2006, l'EHPAD St Vincent accueillait des résidents sans trouble cognitif ainsi que des résidents Alzheimer. Nous avions pu identifier 4 types de diffic","PeriodicalId":20849,"journal":{"name":"Quality and Safety in Health Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88273584","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"270 Improving pharmacological care of the elderly in Alsace","authors":"Passadori Yves, Leveque Michel, Meyer Martin","doi":"10.1136/QSHC.2010.041624.72","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.72","url":null,"abstract":"Background and objectives The creation of the Regional Observatory for Quality in Alsace arose from the synergy between continuous medical education initiatives for general practitioners (GPs) (FMC 68) and initiatives led by the college of French geriatricians (CPGF) and the Regional Hospitalization Agency (ARH) of Alsace. Our programme is a result of this synergy. Its objectives are to improve medication management in the elderly, in or out of hospital, by enrolling general practitioners (GPs), hospital pharmacists, and hospital practitioners in a regional quality management programme. Programme Our quality improvement initiative concerns the pharmacological care of an elderly population (aged over 65 years) with multiple diseases and of a geriatric population aged over 80. Its method is the clinical audit. 2006: Test in a long-term care unit (CM Saales) within the framework of the HAS accreditation scheme for health care organizations (version V2) 2007–2009: Clinical audits by 60 GPs with the support of an HAS certified body 2008: Creation by CPGF of 5 ‘targeted clinical audits’ kits (HAS methodology) relative to drug prescriptions in the elderly December 2008–October 2009: Adaptation of the kits by hospital pharmacy quality group, test of audit criteria, training of hospital pharmacists in kit use, first round of audit, improvement plan. Kit presentation to the coordinating doctors of residential homes for the elderly. January 2010: Second round of audit by hospital pharmacists 2010: Raising the awareness of community pharmacists. Results Sixty GPs (1080 medical records) participated in the three rounds of the clinical audit held in 2007 to 2009. Compliance was poor in the first round for the following audit criteria but improved in subsequent rounds: 2007: Three criteria relating to screening for renal failure (aetiology, exploration, and renal failure stage) 2008: Two criteria relating to risk factors (detecting falls, naming the carer in charge) 2009: Three out of 6 criteria for the prescription of benzodiazepines in the elderly showed poor compliance. Three showed subsequent improvement (treatment duration, short intervention followed by discontinuation, and prescription re-evaluation). Fourteen hospitals (500 prescriptions; medical records) are participating in the audit. Compliance was poor for 4 out of 12 criteria in the first round: (i) no more than two psychotropic drugs (including benzodiazepines) should be prescribed, (ii) creatinine clearance should be given, (iii) the prescription should specify patient weight, (iv) the pharmaceutical form should be appropriate for the patient. Results for the second round are awaited. Discussion and conclusion The impact of this quality initiative on pharmacological care in the elderly is difficult to determine in terms of morbidity and mortality. Appropriate clinical impact indicators need to be developed. However, thanks to the programme, health professionals involved in different types of care","PeriodicalId":20849,"journal":{"name":"Quality and Safety in Health Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83735000","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"080 Prescrire's practice improvement programme","authors":"P. Schilliger, J. Juillard, H. Merlin","doi":"10.1136/qshc.2010.041632.9","DOIUrl":"https://doi.org/10.1136/qshc.2010.041632.9","url":null,"abstract":"Background and objectives A continuous effort is required to improve the quality of individual healthcare practice, through evaluation, exchanges with other professionals, and improvement goals based on robust evidence. Association Mieux Prescrire (AMP), an independent organisation providing continuous education for healthcare professionals, is entirely funded by its subscribers and accepts no subsidies or advertising of any nature. AMP's activities in the fields of continuous education and professional practice evaluation have received accreditation from the French authorities. In 2008, AMP launched a practice improvement programme (PIP), aimed chiefly at healthcare professionals (doctors and pharmacists) working in the primary care sector and who were already enrolled in a Prescrire training programme. The programme is designed to encourage continuous self-evaluation. Programme PIP is an online programme compatible with the constraints of professional practice in the primary care setting. It is based on self-evaluation of individual practices, constructive criticism, and setting goals for improvement. The programme is continuous and lasts 24 months. The first year focuses on implementing goals set by Prescrire, based on reliable clinical data and strong practice recommendations. These goals concern specific actions and patient populations, and are accompanied by solid arguments, referenced data and practical suggestions. Each participant first chooses three sets of three goals, from among a total of 18 proposals, most relevant to their own practice, ie the main types of patient they deal with. During each session the participants analyse their current practices with respect to the different goals, verify after 4 months that they have implemented the proposed improvements, analyse any obstacles encountered, and envisage alternative approaches. Participants can discuss the different goals in specific online forums. Each participant receives an individual assessment report. The second year focuses on the longer term implementation and relevance of the chosen goals, after a 12-month period. The PIP team reviews each participant's six self-evaluations, and their contributions to the forums. These reviews are returned to the participants after anonymisation. They allow the participants to assess the practical relevance of their goals and the feasibility of the programme in the primary care setting. Participants are required to follow the entire programme and to complete the six online questionnaire-based evaluations. Results 799 healthcare professionals entered the programme in January 2008, and 497 of them (62%) continued during the second year. On average, participants reported that they reached their goals in 60%–90% of cases. Taking major public-health objectives by way of an example, the ‘Avoid NSAIDs during pregnancy’ goal was implemented by 77% of participants after 4 months and by 98% at 12 months (among participants remaining in the programm","PeriodicalId":20849,"journal":{"name":"Quality and Safety in Health Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89339153","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"135 Clinical impact of a structured daily staff meeting in an emergency department","authors":"J. Steinmetz, P. Bilbault, B. Gicquel-Schlemmer, B. Christophe, C. Duja, P. Kauffmann, M. Mihalcea, C. Géronimus, C. Kam, J. Kopferschmitt","doi":"10.1136/qshc.2010.041632.21","DOIUrl":"https://doi.org/10.1136/qshc.2010.041632.21","url":null,"abstract":"Context and Objectives The emergency department is a sector with an important clinical exposure in connection with the required quality of care. This is due to the great number of patients seen every day, the variety of clinical situations met and the multiplicity of colleagues involved. The daily staff meeting with the team coming out of duty is an important moment for the continuation of care (hand over, diagnosis and/or treatments readjusted, organisation of the daily department activity, notified dysfunctional issues), but also for training purpose towards the juniors of the team. The new protocol was put in place in October 2006 after we noticed the lack of structure and the excess of verbal exchanges in the meetings. The objectives were the followings: more formal organisation of the meeting in terms of timing and components, improve the quality of hand over (verbal and written), leave a written trace of the decisions and the benefit-risk discussion made by the staff, track down and handle the dysfunctional issues, survey how the patient's records are kept, discuss the topics which will be developed in priority for the education and training of the junior members of the team. Schedule Internal regulations have been written, summed up in an eight points check-list (daily task distribution, hand over, dysfunctional issues, information about the admitted patients, position of each staff member during the day in the department, patient's records keeping…) used by the moderator. At the beginning of each meeting a moderator and a secretary are designated amongst the seniors of the team. A printed sheet is used, one per day. At the end of the meeting, the secretary transfers the predefined key elements on a data base. The results will be shown from to day to day on graphics automatically updated (number of patients admitted, number and type of dysfunctional issues, missing criteria in keeping patient's records, etc). A special dating stamp is used in the patient's records to underline the decisions made and the benefit-risk discussions. According to the case, the dysfunctional issues are dealt with immediately or discussed later at the debriefing meetings. These meetings, held every 2 months, are formally summarised in a report distributed to the different actors involved. Once these data have been surveyed, an agenda of improvement actions is defined and each theme will be allocated to one of the senior colleagues. An indicator follow up is scheduled and a synthetic assessment is established annually. Results After 3 years, 98% of the structured staff meetings were following the protocol. Most of the meetings didn't last longer than the fixed 45 min. Thanks to the collection of the dysfunctional issues a number of improvement actions are put in place, punctual or general actions, development of clinical pathways, procedures, protocols. Audits were realised as well as practise enquiries or relevance analysis. During these staff meetings about 50 p","PeriodicalId":20849,"journal":{"name":"Quality and Safety in Health Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73534849","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"020 How drug prescriptions in intensive care unit could be optimised?","authors":"J. Lehot, C. Lupo, M. Billard, C. Flamens, O. Desebbe, B. Delannoy, O. Bastien, G. Aulagner","doi":"10.1136/QSHC.2010.041632.2","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041632.2","url":null,"abstract":"Objectives Drug prescription represents a large part of costs in intensive care unit (ICU). However this cost is often ignored by intensivists who choose the product apparently most adapted to a clinical situation. This choice should depend on evidence-based medicine and guidelines but they do not exist for many conditions. Therefore, local guidelines can be decided according to the patients and focused on main costs. Regarding cardiovascular and thoracic surgery, a feasibility study was undertaken in a postoperative acute care unit in order to evaluate whether intensivists would accept this challenge and the consequence on patient's outcome. Programme Meetings started on 8 January 2006 with 2–3 sessions a year to analyse the ordering process. The analysis was performed by consultants (intensivists and pharmacists), registrars and residents. The list of drugs costing more than 10 000 euros a year was examined. The drugs appearing indispensable were not discussed. The others were discussed to find out equivalent but cheaper drugs and/or administration modalities (antibiotics, anaesthetics, dopexamine, L-alanyl-L-glutamine) or to limit rationally their ordering (antithrombin III, human albumine, inhaled nitric oxide). New residents were systematically taught about this programme. Meanwhile monthly morbidity–mortality meetings were pursued. Results Years 2006 2007 2008 Open beds (n) 28.8 27.6 27.3 Number of patients (n) 1728 1754 1813 Mean age (year) 53.3 52.8 59.7 ICU total production 2 643 181 2 544 141 2 733 860 (Relative Complexity Index) Mechanical assistances (n) 37 69 103 Costs (euros, VAT incl.): Antibiotics 190 305 127 678 134 426 Antithrombine III 94 115 65 364 70 310 Anaesthetics 92 706 58 384 49 552 Human albumine 80 913 57 708 44 816 Dopexamine 20 546 8 066 9 452 L-alanyl-L-glutamine 12 407 4 096 7 163 Total 490 992 321 296 315 719 Change vs 2006 (%) −34.5 −35.7 Discussion Despite an increased activity and more senior patients, the order of target drugs decreased by 35.7% in 2008 (175 273 euros per year). Antithrombin III ordering decreased by 46.5% despite the dramatic increase in mechanical circulatory assistances. Meanwhile an increase in morbidity and potentially evitable deaths was not observed. However an increase in four drugs was observed in 2008 suggesting that a profit-sharing with ordering physicians is mandatory to obtain longer effects. This policy should be taught to medical students to increase the performance of ordering. Objectif Les prescriptions médicamenteuses représentent une large part des dépenses en réanimation. Cependant, ce coût est souvent ignoré par les réanimateurs qui choisissent le médicament apparemment le plus adapté à la situation clinique du patient. Ce choix devrait dépendre de données fondées sur les preuves et/ou de recommandations mais ces dernières sont inexistantes dans beaucoup de situations. Ainsi, des recommandations locales peuvent être données en fonction des pathologies renc","PeriodicalId":20849,"journal":{"name":"Quality and Safety in Health Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74676147","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"131 Preanalysis nonconformities management in a routine medical laboratory","authors":"F. Fischer, A. Appert-Flory, S. Raynaud, J. Quaranta, J. Levraut, J. Fuzibet","doi":"10.1136/QSHC.2010.041632.19","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041632.19","url":null,"abstract":"Introduction The preanalytic process is a crucial step for the accuracy of results in a routine medical laboratory. It also has a forensic weight. We report a continuous improvement of the quality process in the management of nonconformities in the preanalytical sector of the Haematology laboratory of the CHU of Nice. Brief Outline of Context Main preanalytical nonconformities (NC) observed in our laboratory in 2007 was collected retrospectively. 169 244 adverse events were recorded, (including lack of date/time of blood collection (n=81269), antithrombotic treatment not specified (n=87753), lack of specimen identification (n=93), inadequate filling (n=100) coagulated blood samples (29)), and analysed using the RCA method. After assessment of the problem and analysis of its cause, we identified and applied some improvement actions. Goal To reduce the two most frequent adverse events observed in our laboratory: Adverse event #1: lack of date/time of blood collection (hour and day) (81 269 over 230 476 received prescription forms (35%)) Adverse event #2: antithrombotic treatment not specified. (87 753 over 166 016 received haemostasis prescription forms (53%)) Our goal was to reduce the global monthly percentages to less than 15% for both items. Strategy for Change We chose two medical departments interested in this approach: the adult emergency department and the department of internal medicine. The corrective actions consisted in meetings with the staff of the two departments (physicians and nurses), to form and inform them on the importance to correctly fulfil the laboratory prescription forms, and the consequences of incomplete data on laboratory results quality. During the successive meetings with the staff of both departments (1 per month from January 2008 to June 2008), follow-up of NC percentages was provided and analysed. Measurement of Improvement and Effects of Changes The monthly follow-up of the NC percentages for the two departments involved in the study is reported below: Adverse event #1 adult emergency department: month 1 (32%), month 12 (27%), month 24 (18%) internal medicine department: month 1 (45%), month 12 (27%), month 24 (6%) Adverse event #2 adult emergency department: month 1 (41%), month 12 (45%), month 24 (40%) internal medicine department: month 1 (75%), month 12 (85%), month 24 (75%) Results Adverse event #1: dramatic improvement in compliance with prescription form fulfilment, sustained in 2009 Adverse event #2: we didn't notice any stable improvement on the NC. We have to develop new corrective actions, maybe based on computerised prescription with the obligation to give information about the treatments. Lessons learned and conclusion: Providing objective data is effective in convincing physicians and nurses of the need for change. Continuous follow-up is essential to ensure that changes are fully implemented. Increased sensitivity of the staff to correct errors was not sufficient to reduce the percentage of adverse ","PeriodicalId":20849,"journal":{"name":"Quality and Safety in Health Care","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2010-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73613481","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}