Quality and Safety in Health Care最新文献

{"title":"254 Improving care for congestive heart failure by transfering competency to specialised nurses","authors":"J. Patrick, Funck François, Henegariu Viviana, Boireau Amélie, Dagorn Joël, Adalla Dora, B. Michel","doi":"10.1136/QSHC.2010.041624.90","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.90","url":null,"abstract":"Background Chronic Heart failure management is based on ESC recommendations. In most countries, medical therapy is based on a medical examination and despite the improvement of medical therapies; most of CHF patients are not optimally managed. Nurses are more and more implicated in CHF management. Methods We have compared double blind medical prescription of a Heart failure trained Nurse (specific training on CHF, ESC recommendations, BNP use and pathophysiology, patient education) and a heart failure specialised cardiologist in 120 consecutive patients. We focusing on clinical examination, BNP interpretation, treatment evaluation and therapeutic modifications proposed. Results We have included 120 consecutive patients. Mean age was 70.2±5. Mean LVEF was 32±5%. Mean BNP was 230±120 pg/ml NYHA classification was similar in 85% of cases. Treatment evaluation was similar in 89% of the patients and 96% of patients considered as under optimal therapy by the heart failure specialist were identified by the HF nurse. Therapeutic modifications proposed by HF nurse were confirmed by the HF specialist in 85% of the patients. ESC recommendations were followed in 100% of the cases. Differences in prescription between HF nurse and HF specialist are mainly related to spironolactone/Angiotensin II receptor antagonist introduction in addition to ACEI therapy. Conclusion A trained HF nurse could act as first line prescriber in CHF with a low risk profile. Données actuelles La gestion de l'insuffisance cardiaque chronique est basée sur les recommandations de l'ESC. Dans la plupart des pays, le traitement médical repose sur un examen médical et en dépit de l'amélioration des thérapies, la plupart des patients atteints d'ICC ne sont pas géré de façon optimale. Les infirmières sont de plus en plus impliquées dans la gestion de CHF mais ont encore un rôle limité à la prise de cosntantes et de prélèvements. Méthodes Nous avons comparé en double aveugle la prescription médicale d'une infirmière formée spécifiquement à insuffisance cardiaque (formation spécifique sur la maldie, les traitemetns, les bilans et la façon de les interpréter, les recommandations de la société européenne de cardiologie, l'utilisation du BNP et de la physiopathologie, l'éducation des patients) et un cardiologue spécialisé chez 120 patients insuffisants cardiaques consécutifsen nous concentrant sur l'examen clinique, l'interprétation de la BNP, l'évaluation des traitements thérapeutiques et des modifications proposées. Résultats Nous avons inclus 120 patients consécutifs. L'Âge moyen était de 70.2±5. La FEVG moyenne était de 32±5%. Le BNP moyen était de 230±120 pg/ml, la classe NYHA a été similaire dans 85% des cas. Traitement de l'évaluation a été similaire dans 89% des patients et 96% des patients sous traitement considéré comme optimal par le spécialiste en insuffisance cardiaque ont été identifiés comme tels par l'infirmière spécialisée","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":"83505028","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":"276 Improving the quality of prostate cancer diagnosis and treatment using shared clinical practice indicators (CPI) and a computerised clinical pathway","authors":"X. Rébillard, B. Ségui, A. Faix, S. A. Hamid, T. Murez, R. Daniel, N. Riolacci, M. Erbault, A. Desplanques, D. Pierre, P. Coloby","doi":"10.1136/QSHC.2010.041616.12","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041616.12","url":null,"abstract":"Background and Objectives In France, prostate cancer is the most common cancer in men (71 000 new cases expected in 2009) and the second cause of mortality from cancer (8600 deaths expected in 2009). About 180 000 biopsies are made each year, enabling diagnosis of the disease when still at a localised stage in 70% of cases. Radical prostatectomy (RP) (about 25 000 per year) is a therapeutic option for localised cancer requiring the management of the risk of incomplete tumour excision as well as of postoperative functional morbidity. In 2009, the French Parliamentary Office for the Assessment of Health Policies underscored inconsistencies in prostate cancer management that impact on functional morbidity and mortality. Our objective was to develop clinical practice indicators (CPIs) for inclusion in a computerised clinical pathway to be able to propose improvements in care, whether with regard to diagnostic or therapeutic decisions. Programme The CPIs were based on clinical practice guidelines selected by a panel of urologists and validated by the French Association of Urologists (AFU). The innovative computer system Normind-diagnosis was used to calculate CPI values from patient records. The feasibility and quality of CPI data collection by Normind-diagnosis was validated in an analysis of records from five urology departments and national or regional databases (multidisciplinary review of medical records, the pathology database of CRISAP-LR, the national ABLATHERM registry, and the FRANCIM 2001 cohort). The criteria for assessing the quality and safety of diagnostic and therapeutic care in RP patients were: Quality of the histology report (compliance with the recommendations of the AFU Cancer Committee (CCAFU) and the French Society of Pathology), Correct selection of patients eligible for surgery (D' Amico risk classification, comorbidities) and safety of surgery (transfusion rate), Efficacy in oncological terms (negative surgical margins, undetectable PSA at 3 months), and Detection of postoperative functional morbidity and assessment of quality of life (continence at 1 year, erectile dysfunction at 2 years). Results A total of 545 patients with prostate cancer diagnosed in 2007–2008 benefited from CPI monitoring. The CPIs could be calculated from 89% of patient records: In 2008, 100% of biopsy histology reports complied with CCAFU criteria versus 67% in 2007. The D'Amico prognostic group was determined in 98% of patients. For 185 patients who underwent RP, the decision was completely in line with all good practice criteria in 89% of cases; 1% of patients had transfusions. Surgical margins were negative in 84% of patients; 97% had undetectable PSA at 3 months. 91% of patients were totally continent at 1 year. Data for erectile dysfunction are not available. Discussion and Conclusion This computerised clinical pathway using CPIs is currently being implemented by eight urology teams in three regions in France within the framework of a quality res","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":"90334289","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":"112 Why perform bacterial identifications and antibiotic sensitivity analyses during night shifts in a bacteriology laboratory in a university medical centre?","authors":"E. Matthieu, L. Carole, C. Jané, Hitoto Hikombo, Mahaza Chetaou, Kempf Marie, Joly-Guillou Marie-Laure","doi":"10.1136/QSHC.2010.041624.6","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.6","url":null,"abstract":"Background, objective After opening hours, the activity of a clinical microbiology laboratory (CML) is usually limited to the inoculation of specimens sent by clinical wards and gram-stain examinations. A continuous functioning (CF) has been implemented for the last 4 years in the CML of Angers teaching hospital. With the CF, in addition to gram-stain examination and inoculations, urine cultures, blood cultures and cultures from certain fluids (ascitis, articular, pleural, perioperative, cerebrospinal) are monitored two or three times every night. In the case of colony growth, bacterial identifications (BI) and susceptibility to antibiotics testing (SAT) are performed. Concurrently to a geographical grouping of our hospital laboratories expected in 2010, the permanence of the CT is questioned. Therefore, our objective was to assess its interest in order to maintain it. Program: description, implementation, follow-up For each specimen for whom a BI and/or SAT were performed by night, the impact of the CF was assessed in terms of decrease in the delays from the time of sampling to the time at which results became available, and in terms of consequences of this decrease for the management of patient antimicrobial treatments. The delays in the absence of CF were estimated by considering the laboratory opening hours in the absence of CF and delays in incubation necessary for BI and SAT. Two major benefits have been defined: the early implementation of an effective treatment (EIET) and the early change to a reduced-spectrum but still efficient regimen (ECRR). The decrease of the delay was either 24 h or 48 h. Results in terms of clinical impact During the 4 months of the study, a BI and/or a SAT were performed for 430 specimens during the night period. An EIET was reported for 97 samples (22.6%), representing a cumulative gain of 111 days. For 49 patients, this EIET corresponded to the modification of an ineffective treatment, and for the 48 others, it corresponded to the implementation of an effective treatment in a patient not treated. An EIET was observed in 37.9% of blood cultures, 20.8% of urine cultures, and 17.9% of fluid cultures concerned by the night activity. An ECRR was reported for 23 samples accounting for 5.4% of overall specimens and representing 29 days of treatment. Among the nine wards for which the CF was the most profitable in terms of EIET, there were seven medical and two surgical wards. Therefore, there was no intensive care unit (ICU) among those wards. Similarly, the medical ICU was only in fourth position in terms of ECRR. Discussion, conclusion Even though an economical study would have been useful, this system, unique in France, is helpful to improve the proper use of antibiotics. Unlike a classic night functioning for whom the results of gram-stain examinations are reported by night, often in the absence of clinician, the night activity in our CF allows to provide results during the day period (with 24 or 48 h in advance),","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":"75222436","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":"149 Follow-up of adverse events in a neonatal intensive care unit","authors":"L. Stephanie, Razafimahefa Hasinirina, Sgaggero Betty, Brosseau Martine","doi":"10.1136/QSHC.2010.041624.46","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.46","url":null,"abstract":"Context Iatrogenic incidents, major public health problem, can be responsible for damage and serious after-effects, particularly in neonates. They would be responsible for complications in 10% of the hospital admittances. Newborn children are particularly exposed to these iatrogenic risks. Several studies showed that these incidents increase significantly the risk of morbi-mortality in paediatric departments. Only few data are available on their incidence and consequences in neonatology. Objective of this work was to determine the epidemiology of iatrogenic risks in neonates, to look for answers to these dysfunctions and to sensitise medical and paramedical professionals to this public health problem. Description of the program A multidisciplinary group called ‘Amélioration des soins à l'enfant’, with monthly medical and paramedical meetings for synthesis and exposition of the results, was created in 2005. The group defined the methodology of the program, set up a continuous statement of adverse events (AE), analysed the data and identified corrective actions to AE. In 2008, this approach was continued with modified objectives and two nurses were associated in the five following domains: respiratory, intravenous, oral tract and skin incidents and incidents concerning the management and the organisation of care. An anonymised form was created in each domain to improve the exhaustiveness of the data. Results In 2005, 171/248 (70%) of the AE concerned the parenteral route, especially central (45%). Twenty cases of catheter removal secondarily to catheter obstruction were collected. Identification of the causes of these obstructions allowed the introduction of corrective actions (reprogramming of pumps, change in use of solutions). Thus, obstructions became less frequent (6) and did not require catheter removal any more. From November 2008 to January 2009, 205 AE were collected. The main problem identified was the presence of water in the respiratory tubes during non-invasive ventilation (30/93 cases of respiratory incidents), responsible for episodes of deep bradycardia and desaturations in children. Contacts with biomedical service, with other neonatal intensive care units and with tube manufacturers demonstrated that the solution was to use another equipment (dual hose heater adaptator for respiratory system) to avoid condensation. An inventory of our equipment followed by the purchase of all the necessary material at the beginning of February 2009 allowed the disappearance of this AE within our department. Discussion Improvement of the tool to collect AE is the principal objective of our group. It will allow a better exhaustiveness and then, a more rapid reaction in the introduction of corrective actions. Other objectives are the information and the knowledge updating of health care workers and the review or the elaboration of new protocols. One limit of this work is the reluctance of health care workers to report AE, as they consider AE as a r","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":"77097056","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":"159 Sleep apnoea: clinical impact of a quality improvement program using an Internet-based registry","authors":"J. Pépin, G. Huchon, Y. Grillet, M. Sapéne, A. Vicente, B. Housset, Au Nom Des Membres De L'osfp","doi":"10.1136/QSHC.2010.041608.9","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041608.9","url":null,"abstract":"Background and Objectives The national French Registry to evaluate sleep breathing disorders (OSFP Registry: Observatoire sommeil de la Fédération de Pneumologie) is intended to collect updated information about current practices of respiratory physicians managing sleep apnoea patients. Methods, Program Description and Follow-up The main goal of the Internet-based registry (www.osfp.fr) is to improve clinical management quality by offering respiratory physicians a complete and systematically organised online evaluation of patients referred for sleep disorders. The content of the registry addresses four goals: (1) to improve physician's knowledge not only of sleep apnoea but also of alternative diagnosis by the systematic use of validated clinical scales for sleepiness, fatigue, depression and restless legs syndrome, (2) to increase awareness of comorbidities and cardio-metabolic risk associated with sleep apnoea, by suggesting measurements of waist circumference, blood pressure, fasting lipids and fasting glucose, (3) to identify subgroups of at-risk patients (ie obesity hypoventilation and a combination of chronic obstructive pulmonary disease and sleep apnoea, the so-called overlap syndrome), and (4) to suggest appropriate follow-up and treatments for these specific subgroups of patients according to national guidelines. Information from the database is available at anytime and data can be extracted for statistical analysis. Participating physicians can compare their practices with others’ in the registry and with the guidelines established with the French High Health authority (HAS: Haute Autorité de Santé). Results in terms of clinical impact More than 560 centres were involved and between January 2007 and November 2009, more than 22 000 suspected sleep apnoea patients were enrolled. These centres included varied clinical practices, reflecting real life sleep apnoea clinical management in France. The majority of centres were private practices (74% of the patients) whilst others were public hospital practices, either teaching university hospitals (4% of the patients) or district hospitals (22% of the patients). Patients from all regions of France were included and constitute a representative sample in terms of places of residence, rural/urban ratio and socio-professional groups. Sleep apnoea was diagnosed in 80% of referred patients and CPAP prescribed in 70% of them, with a mean CPAP usage of 5.7 h/night which is higher than the usually reported compliance in clinical studies (Cochrane 2009: 5.5 h/night). Significant improvement occurred with reduction in the sleepiness, fatigue and depression scales (from 12 to 8, 14 to 9 and 6 to 4.5, respectively). Appropriate characterisation of the patients at baseline allowed the identification of cardiovascular comorbidities in 45% of the patients. A significant percentage of patients (11%) were referred to cardiologist or other specialists after associated or alternative diagnosis had been appropr","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":"84701478","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":"282 Reducing the iatrogenicity of neuroleptics in patients with Alzheimer's disease","authors":"A. Desplanques-Leperre, N. Riolacci-Dhoyen, M. Erbault, L. Banaeï-Bouchareb, C. Chan-Chee, J. Deligne, V. Corre, P. Ricordeau, B. Lavallart","doi":"10.1136/QSHC.2010.041608.21","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041608.21","url":null,"abstract":"Background and Objectives Neuroleptics (NL) are often prescribed to patients with Alzheimer's disease (AD), mainly for behaviour disorders and during episodes of confusion. However, these drugs are known to have frequent and severe iatrogenic effects: treating 1000 patients with behaviour disorders receiving NL for 12 weeks would result in 10 additional deaths, 18 strokes (half of which were severe), additional 58 to 94 cases of gait disorders and only 91 to 200 decrease in behaviour disorders. In fact, all AD patients will present behaviour disorders at some time or other. The French Alzheimer public health plan aims to reduce the avoidable iatrogenic effects of NL. Program The national cooperative group for the optimisation of the prescription of psychotropic drugs in the elderly was established at the initiative of HAS. Its members include nurses, patients, insurers and institutions. A problem-solving approach centred on the patient pathway that included three quality dimensions (Efficacy (E), Safety (S) and Access to best care (A)) was used to develop and implement the tools to achieve an integrated programme going ‘from practice improvement to clinical impact measurement’. The practice improvement part which is aimed at reducing the iatrogenic effects of NL in AD patients includes: (1) identification of AD patients with NL (local warning signal=percentage of AD patients taking NL). This indicator is easy to measure in all care sectors and comes with a good practice indicator ‘absence of daytime sedation’ and monitoring of prescriptions for other psychotropic drugs to prevent drug switching, (2) review of prescriptions for identified AD patients in order to correct inappropriate prescriptions (local indicator for risk containment=percentage of prescriptions reviewed for AD patients), and (3) two new guidelines on behaviour disorders in AD patients and on confusion in the elderly that describe proper use of NL and other psychotropic drugs (E, S) as well as new nondrug techniques of care (A). Reduction of exposure to NL before and after prescription is based on these guidelines. Clinical impact is given by the national rate of exposure of AD patients to NL and is measured in the French AD patient population covered by the three main sickness funds. Results The first national measures in 2007 on 400 000 AD patients showed that exposure to NL in AD patients was five times higher (16.95%) than in the general population of the same age (2.9%). One year after the Alzheimer plan was launched and after raising the awareness of families and health professionals to the risks of NL, exposure had fallen slightly to 16.1% (equivalent to 3500 fewer cases of exposure). The above programme is in the process being implemented. Results for the national warning signal have been widely diffused. The programme is supported by training initiatives and information campaigns aimed at the general public, the families of AD patients, and health professionals. These are","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":"82865853","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":"291 Improved management of surgical paediatric patients by computerised selection of medical files for analysis in morbidity monitoring staff meetings","authors":"J. Breaud, Griffet Jacques, Julie Manuel, Bensaid Ronny, M. Carine, J. Quaranta","doi":"10.1136/QSHC.2010.041624.37","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.37","url":null,"abstract":"Background and objectives For Morbidity Monitoring Staff (MMS) meetings to be efficient, they need to include all patient files concerned with medical failures or logistics failures. The major difficulty is selecting all relevant files. Our objective was to develop a computer application that would select the files that need to be discussed in order to identify medical failures and logistics failures that need remedying. Programme The computer application for automatic file selection is based on a comparison of the actual length of hospital stay with the predicted length of stay for a given disease and/or surgical procedure. Every 2 months, all selected files are reviewed to determine which files are incomplete, which relate to medical failures, and which to logistics failures. Results During the 30-month period from January 2006 to April 2009, 8540 children underwent surgery in our department. A total of 1364 (16%) medical files were automatically selected for review by MMS. A total of 51 cases (0.6%) of medical failure and 16 cases (0.19%) of logistics failure were identified and analysed. Three improvement actions ensued: (i) the development of a specific multidisciplinary medical file for ASA III patients, (ii) routine bacteriological analysis in cases of appendectomy in order to fight antibiotic-resistant infections better, (iii) changes in the organisation of day-care surgery (phone-call the day before and after surgery, changes in the timetable…) Conclusion The automated procedure for the selection of medical files for review by MMS helped us identify medical failures (0.6% rate) and initiate specific actions in order to improve health care delivery in our department. Our tool may be useful for MMS in all cases of scheduled hospitalisation or elective surgery. Introduction l'amélioration des pratiques professionnelles repose entre autre sur la réalisation au sein des équipes médicales et paramédicales de RMM. Toutefois, la sélection des dossiers à analyser dépend le plus souvent d'une évaluation individuelle de la survenue d'un évènement porteur de risque ou d'une complication et n'est pas toujours exhaustive. Afin de pallier à cette situation, nous avons développé un système automatique de sélection des dossiers à analyser, basé sur la durée du séjour hospitalier et le caractère complet ou nom du dossier (présence de résumé d'activité médicale et de compte rendu opératoire). Ce mode de sélection nous permettant d'extraire les dossiers incomplets et de les finaliser, mais aussi de mettre en exergue les complications médicales et les problèmes organisationnels. Matériel et méthodes Une application informatique développée sur le logiciel ACCESS (microsoft*) permet, pour chaque patient opéré dans le service, de comparer la durée de l'hospitalisation effectuée à la durée prévisible de l'hospitalisation pour la pathologie et le geste chirurgical concerné. Ainsi, tout patient dont la durée dépasse la d","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":"91418797","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":"259 Measure of the impact of the implementation of organised stroke care in the region lle-de-France","authors":"F. Woimant, R. Simon-Prel, M. Neveux, M. Degrave","doi":"10.1136/QSHC.2010.041608.17","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041608.17","url":null,"abstract":"Context and Objectives Numerous studies and metaanalysis showed the efficiency of Stroke Units (SU). Organised care has been proven to decrease morbidity and mortality after stroke. In Ile-de-France, there are 16 SU, and among them 10 were created since 2003. The implementation of the SU and of their networks are regularly evaluated on behalf of the regional hospitalisation agency (ARH-IF), with information feedback to multidisciplinary stroke teams and hospital administrators to optimise the quality of care of stroke patients. Description of the Program Two types of indicators are collected. Epidemiological data such as number of hospital admissions for stroke in the region and by territory and establishment and demographic data of stroke patients are analysed. Since 2000, they are collected from the national hospital discharge database, according to a protocol of extraction defined by the professionals. Other indicators concern the hospital management of stroke patients such as proportion of patients admitted in SU vs other nondedicated units, the type of stroke (transient ischaemic attacks, infarction and haemorrhage), the stroke severity, the treatments (including rehabilitation), the complications, the length of hospital stay and the outcome. Time indicators are important to assess the organisation of the care: delay of hospitalisation, of admission within the SU, of access to the neurological expertise, to the brain imaging, to the physiotherapist and speech therapist evaluation and to the stroke rehabilitation unit. These data are prospectively collected from surveys regularly realised on 30 to 50 consecutive patients admitted in SU and stroke rehabilitation wards. A web-based tool was used to collect data from sites. The analysis is realised by the pole ‘Affaires hospitalières de la CRAMIF’. The results of these evaluations are presented during an ARH-IF plenary session to the neurologists, the rehabilitation physicians and the hospital administrators of the concerned establishments, and then within each establishment with all the medical and non-medical multidisciplinary team and the directors. Results These evaluations permit to estimate, in an iterative way, the professional practices and to suggest actions to improve organisation of stroke care, measured in particular on patients' proportion admitted in SU, on the decrease of pre-and intra-hospital delays allowing more patients to have access to the thrombolytic therapy. Within Ile-de-France”, the number of stroke patients admitted in establishments with SU increased from 22% to 48.5% between 2003 and 2008; the median age of stroke patients did not modify in the region (71 years), but the age of stroke patients admitted in establishments with SU increased from 63 to 67 years. The in-hospital stroke mortality decreased from 15.8% to 10.5% and the SU- mortality from 12.5% to 8.6%. The number of patients evaluated within the first 48 h by a physiotherapist and/or a speech therapist incr","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":"83583950","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":"133 Clinical pathways in post-anaesthesia care unit to reduce length of stay, mortality and unplanned intensive care unit admission","authors":"A. Eichenberger, G. Haller, B. Walder","doi":"10.1136/QSHC.2010.041624.31","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.31","url":null,"abstract":"Introduction The aim of the study was to assess the impact of a clinical pathway implemented in a post-anaesthesia care unit (PACU) on postoperative outcomes. Methods A patient clinical pathway which includes a nurse-driven fast track program (FTP) for uncomplicated patients and minor interventions and a medical-driven slow track program (STP) for complicated patients were implemented over a period of 2 months. A retrospective cohort study based on electronic patient records was performed to assess the effectiveness of this program on PACU and hospital length of stay (LOS) and in-hospital mortality and unplanned admission to the intensive care unit (ICU). We compared the period before and after implementation of the program. Statistical analysis was performed using the Student t test, χ2, Wilcoxon-rank test. Multivariate analysis using linear and logistic regression was performed to adjust for differences in patient demographic characteristics, co-morbidities, type of surgery and anaesthesia and emergency status between the two periods. A p≤0.05 was considered significant. Results Patients characteristics, ASA scores, type of anaesthesia and surgery were similar before and after implementation of the clinical pathways. We observed a decrease in PACU median length of stay for all patients from 163 min (IQR, 103–291) to 148 min (IQR, 96–270 min) (p<0.001). In ASA 1-2 patients median LOS in PACU decreased from 152 min (IQR, 102–249 min) to 135 min (IQR 91–227 min) in ASA 1-2 patients (p<0.001). Hospital LOS however remained unchanged. Overall in-hospital mortality after pathway implementation decreased for all patients from 1.7 to 0.9% (adjusted OR 0.36 (95%CI 0.22 to 0.59), p value<0.01). The number of unplanned admissions to ICU decreased also from 113 (2.8%) to 91 (2.1%) (adjusted OR 0.73 (95%CI 0.53 to 0.99); p value 0.04). Conclusion A significant reduction of LOS in PACU, in-hospital mortality and unplanned admission to ICU was observed after implementation of a clinical pathway in the PACU. Introduction La phase postopératoire est une phase risquée pour le patient en terme de complications. La mortalité postopératoire actuelle, tous actes chirurgicaux confondus, se situe entre 1.2 et 2.6%, alors que la morbidité est supérieure à 11%. Dans notre salle de surveillance post-interventionnel (SSPI), nous avons un flux important de patients en bonne santé habituelle ayant bénéficié d'un acte chirurgical mineur et des patients polymorbides ayant bénéficié d'une chirurgie majeure. Nous avons mis en application un programme de prise en charge des patients permettant de libérer rapidement ceux en bonne santé habituelle sur la base de critères cliniques standardisés de manière à libérer les ressources de soins nécessaires pour la prise en charge des patients à haut risque de complications. But de l’étude Le but de cette étude était d’évaluer les bénéfices d'un programme de qualité incluant deux itinéraires cliniques distin","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":"85897084","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":"148 Patient information: definition of indicators on the quality of disclosures to patients","authors":"A. Vitoux, F. Farsi, C. Grenier","doi":"10.1136/qshc.2010.041632.26","DOIUrl":"https://doi.org/10.1136/qshc.2010.041632.26","url":null,"abstract":"Context and Objectives The disclosure protocol, defined in the first French cancer plan, is intended to benefit patients, giving them better conditions for disclosing their illness and the treatment plan proposed, and this throughout its management. This protocol relies on a multidisciplinary management involving primarily physicians (medical time) and paramedics (accompanying time) and aims to inform and accompany the patients and their family. The quality of patient information is considered as a crucial point for quality of care. Our program has been set up to improve its modalities. The objectives of this program are the following: Description of the current situation, Feedback on experiences Implementation of improvement projects Demonstration of the progress made Programme Six Comprehensive Cancer Centers (CCCs) were involved in a voluntary program. First, the most important aspects of the disclosure protocol were identified. Six valid, reproductible and discriminative quality indicators (QIs) were developed. Each of these QIs includes several items. The relative weight of each item was defined from the quotation of items by participants and experts in terms of relative importance. Each QI was quoted on a scale from 0 to 1. In the CCCs involved in the program, an audit (September 2008) was performed using medical records of 60 new patients who were under treatment (surgery, chemotherapy and/or radiotherapy) for a new cancer. This retrospective audit was used to establish the state of practices. Professional practices were benchmarked between the different CCCs and weaknesses were identified. Improvement actions to be implemented have been discussed and a specific quality plan has been set up in each CCC. Results The assessed QIs were respectively: the disclosure process: mean score=0.63, range: 0.53–0.76 continuity of care: mean score=0.61, range: 0.00–0.75 consideration of patient needs: mean score=0.46, range: 0.26–0.68, information delivered to the patient: mean score=0.28, range 0.25–0.30, patient feelings: mean score=0.27, range 0.09–0.37 needs of relatives for support: mean score=0.26, range 0.02–0.44 Even if the lack of traceability may explain a large part of measured quality defaults, professionals also identified the need to precise the good practices, to disseminate them and to structure the modalities of the disclosure process for each patient. This process has been standardised in each center. A systematic production of a personalised care program for each patient is still ongoing. Some skills have already been developed by professionals (e.g. information delivered to the patient, information process, adaptation to patient singular choices, information check list) and shared between CCCs. Conclusion The second audit will be conducted in February 2010 and the comparison of results for each hospital may demonstrate the progress made. Thus, consistency of such programs can be discussed in April 2010. Such an approach is required i","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":"90803090","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}