Quality and Safety in Health Care最新文献

{"title":"011 Reduction of the rate of episiotomies","authors":"Vendittelli Françoise, H. Céline, M. Aurélie, Tergny Etienne, J. Sophie, Accoceberry Marie","doi":"10.1136/QSHC.2010.041624.38","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.38","url":null,"abstract":"Background, objectives Episiotomy rates are a national concern and a major source of dissatisfaction among healthcare users. National good practice guidelines (GPG) issued in 2005 recommended that the episiotomy rate should be reduced to less than 30% (http://www.cngof.asso.fr). Nonetheless, some countries have much lower rates and the figure of 20% should be reachable without difficulty. The Clermont-Ferrand university hospital centre (UHC) has two maternity units. In 2004, maternity ward 1 had an episiotomy rate of 29.25% and maternity ward 2, 39.27%. The principal objective of the programme described herein was to reduce these rates. Programme An indicator approach was chosen with annual follow-up of the overall episiotomy rate, to begin in 2006. In 2005, ward 1 had an episiotomy rate of 22.35% and ward 2 of 33.62%. A retrospective targeted clinical audit was also performed on 100 case files covering the period from 1 July though 1 December, 2005. The indication for the episiotomy was reported in 48% of cases, the name of the person who performed it was available in 87%, and the name of the person who did the repair in 86%. The type of thread used was available in only 68% of cases. A complete report of the repair was included in 64% of the files. No file included a pain assessment. The use of anaesthesia during the repair was noted in 90% of cases and all cases with suture complications included a medical observation. Steps were taken and activities conducted to reduce the rate between 2006 and 2008. They consisted of the annual dissemination of the episiotomy rate compared with the regional rate to all midwife managers (for further dissemination) and to physicians. The Auvergne Perinatal Health Network (RSPA) also relays this dissemination each year. Awareness campaigns were conducted for healthcare professionals, during inhouse departmental meetings or regional conferences, over a 3-year period. A structured computer file was developed and made available to all; it includes items related to episiotomies and allows direct viewing of all national guidelines including on those on episiotomies. Finally, training was provided for interested volunteer midwives and physicians in delivery positions other than dorsal decubitus. Clinical impact Over this period the overall episiotomy rate has fallen markedly: in 2008, it was 19.34% in ward 1 and 17.93% in ward 2. A second targeted clinical audit was performed on 85 files of women who gave birth in one of our two maternity wards between 1 July and 1 December, 2007. It showed an improvement in all the criteria considered in the audit except for the assessment of pain during the repair. Since 2006, annual comparisons have been conducted with national rates, via the Audipog registry, and with regional rates via the RSPA. Discussion, conclusion The working group decided at the end of 2009 to close this practice evaluation process, but to continue to provide the teams with their episiotomy rates together w","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":"78272779","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":"026 Formative assessment using audit and feedback to improve nuchal translucency image quality","authors":"N. Fries, M. Fontanges, M. Althuser, G. Haddad, J. Chabot, O. Scemama, M. Duyme","doi":"10.1136/QSHC.2010.041608.4","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041608.4","url":null,"abstract":"Background and Objective Ultrasound measurements of nuchal translucency and crown-rump length during the first trimester of pregnancy are already used efficiently to detect chromosomal abnormalities. This method can detect between 70% and 90% of Down's syndrome cases, with a false-positive rate of 5%, depending on whether this risk estimation is combined solely with the risk due to maternal age or also with first or second trimester maternal serum markers. However, the performance of this technique depends largely on the precision of ultrasound measurement. The objective is to study the impact of feedback on the improvement of ultrasound scanning practices during the first trimester of pregnancy. Program The Collège Français d'Echographie Fœtale (CFEF) has encouraged its members to participate in practice assessment programs. It has set up a protected Web site (https://nuque.epp-echofoetale.fr/) devoted exclusively to auditing programs and feedback on foetal scanning. 506 sonographers each sent 30 consecutive images to a dedicated, protected server for double-blind, independent and remote analysis by the new CFEF/CNRS image-scoring method. After scoring, sonographers were classified into low (<13/20) or high (≥13/20) scorers. Out of these 506 sonographers, 88 sent a second set of 30 images, 73 of whom had received a feedback report by e-mail and 15 who had received no feedback. No evidence of sampling bias was shown between different groups. Results The scores of the sonographers who received feedback increased significantly between rounds from 11.1±1.3 to 13.4±1.4 for low scorers (p<0.00001) and from 15.1±1.2 to 16.0±1.4 for high scorers (p<0.001), unlike the performance of sonographers who received no feedback increase from 10.9±1.5 to 12.1±2.0 for low scorers (p=0.11), no change (14.7±1.3 to 14.6±1.3) for high scorers (p=0.99). Feedback prompted a 48% increase in satisfactory images in low scorers. Discussion In our study, the adjusted risk difference for the number of satisfactory ultrasound images was 0.22 for low scorers and 0.11 for high scorers. The adjusted risk ratios were 1.48 and 1.15, respectively (increases of 48% and 15%, respectively). Thus the relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low. Our feedback system favours this improvement, since the report not only provides an overall score, but also allows sonographers to see all those shots which are judged inadequate by the rater, and this is valid for each criterion. However, our study also shows that the improvement in practice has its limits. Low scorers improved but did not achieve the performance of high scorers in the first round. As 30% (150/506) of our starting population were low scorers and as 33% (11/33) of these low scorers did not achieve a high score in the second round, we can conclude that, overall, 10% (0.33×0.30) of sonographers will probably not attain a high score after moderately in","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":"82715992","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":"290 Quality circle prescribing improvement program","authors":"G. Arnaud","doi":"10.1136/qshc.2010.041608.22","DOIUrl":"https://doi.org/10.1136/qshc.2010.041608.22","url":null,"abstract":"More than ever, general practitioners (GPs) must adapt their practice through more collective work procedures. Patients and government expect them to ensure quality care at the lowest cost, implement public health programs and maintain primary care on the whole territory. By joining a quality circle, as in the ‘Groupes qualité’ program, a GP may compare his practice to fellow practitioners, rely on evidence-based medical information and access advise from experts. Less isolation and a true professional project are expected. As a territorial scheme, quality circles lead to a real collective work within GP groups and with other professionals. Regional doctor organisations (URML) sided with regional public health insurance administrations (URCAM) to promote these ‘Groupes qualité’. This unique project was initiated in Brittany (West France) in 2000 and now involves 2000 highly loyal GPs in 10 regions. One topic taken from one group's works illustrates the program's impact on healthcare efficiency: acute cystitis for young women with no associated factor of risk. Some items demonstrate that ‘Groupes qualité’ GPs had changed their practice towards better abidance to medical references. In Brittany, for these GPs, a 0.6 pt drop was noticed in the number of female patients with the following characteristics: short or one dose treatment associated to urine culture within a 2-day period. At the same time, this rate climbed 0.8 pt for patients cared for by GPs who were not involved n the ‘Groupes qualité’ program. Many positive results were also observed in treatments for adult asthmatic patients, diabetes and aged persons polymedication. Les médecins libéraux sont confrontés, aujourd'hui plus que jamais, à la nécessité d'adapter leur exercice professionnel en développant notamment des organisations de travail plus collectives pour garantir à la population et aux pouvoirs publics des soins de qualité au meilleur coût, développer des programmes de santé publique et maintenir une offre de soins de premier recours répartie sur le territoire. Outre l'amélioration de la qualité des soins, la participation à un groupe d’échange de pratiques comme le « Groupe qualité », où le médecin peut confronter sa pratique à celle de confrères, s'appuyer sur une information objective scientifiquement validée et recourir aux avis d'experts, peut permettre de sortir de l'isolement et de construire un véritable projet professionnel. Les groupes qualité constituent une animation territoriale et permettent de réaliser un véritable travail collectif à la fois dans des groupes et en collaboration avec d'autres professionnels de santé. Conscientes de l'intérêt d'une telle démarche, les Unions Régionales des Médecins Libéraux et les Unions Régionales des Caisses d'Assurance Maladie se sont mobilisées pour mettre en place des « Groupes qualité », au sein d'un partenariat fort, reconnu facteur de réussite dans le développement de la démarche","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":"82433765","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":"162 Evaluation of lung cancer (L.C.) support from multi-disciplinary consultation meeting (M.C.M.): 10 years experience in à French general hospital","authors":"V. Laurent, Biel Pierre, Cabrera Josianne, Pasto-Catusse Mérixel, Norkowski Jean-Luc, Couderc Bernard, B. Rolland","doi":"10.1136/QSHC.2010.041624.13","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.13","url":null,"abstract":"Since 1998, the hospital of Saint-Gaudens, in the West South of France, has a computerised M.C.M. in the oncology network ONCOMIP with an exhaustiveness of 100% for the L.C. We present the evaluation of our practices, according to the recommendations of cancer plan. Material and method Retrospective analyzes of all the cases of histologically confirmed primitive L.C., submitted at least once in M.C.M., from October1998 to June 2008. Exclusion: files incomplete, followed <6 months and lost sight. Endpoints Times from diagnosis to M.C.M. and to treatments; match between the proposals, guidelines and carried out treatment; follow-up and survivals. Studied population 201 primitive L. C. cases retained, among 248 submitted in M.C.M. - H/F: 4.9—Average age: 69 years (42-94)—WHO performance status 0 or 1: 43.7%—medium or heavy comorbidities: 67.6%—Small cells: 17%—Adenocarcinomas: 23%—Squamous: 44%—T4: 59%, T3: 27%–N3: 50%, N2: 27%–M1: 48%. Patient supports Times from diagnosis to M.C.M.: 23 days, from M.C.M. to treatment: 11 days—Adequacy of the proposals: with the regional guidelines: 97%, with the treatments carried out: 96%—Submission of cases to the teaching hospital M.C.M. (for thoracic surgery): 12%—Inclusion in a clinical trial: 3%—Surgery with curative aiming: 7.8%—Radio-chemotherapy: 45% (exclusive concomitant radio-chemotherapy: 8%)—Exclusive Chemotherapy: 45%—Exclusive symptomatic radiotherapy: 5%—Exclusive palliative care from the start of supports: 17% Results Survivals according to stages are similar to others recent data1 2 Inside the stages, survival rates vary significantly depending on the co-morbidities and the WHO performance status (p<0.001). Chronological benchmarking on three periods does not show gain survival, despite a significant shortening of time to support. Conclusion Evaluation of the L.C. support within a territorial cancer network is desirable and feasible. Despite a strict application of the recommendations, survival rates remain low. They are related to the status of patients as to the spread of the disease and do not appear clearly influenced by the speed of processing start-up. Stage N. 1 year 3 years 5 years Médians I et II 19 84% 53% 32% 49 month IIIA 12 75% 17% 8,3% 28 month IIIB 74 42% 5,4% 1,5% 13 month IV 96 30% 1% 0% 9.5 month Contexte, objectifs Depuis 1988, le centre hospitalier de Saint-Gaudens a mis en place une R.C.P. informatisée au sein du réseau ONCOMIP, avec une exhaustivité de 100% pour les C.B.P. Pour chaque cas présenté les informations suivantes sont requises: démographie, antécédents, comorbidités et facteurs de risque, histoire de la maladie, date du diagnostic, type histologique, classification T- N-M, performance status O.M.S., état du malade, historique des traitements. Un compte-rendu est édité adressé aux médecins en relation avec le patient avec une proposition thérapeutique argumentée en référence aux guides de pratique (nationaux puis régionaux). 10 après nous avons","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":"89951456","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":"169 reduction of hospital acquired MRSA bacteremias further to implementation of a continuous quality improvement program centered on cross-transmission prevention and antibiotic stewardship","authors":"A. Chalfine, B. Misset, M. Kitzis, Y. Bézie, Laurence Perniceni, J. Nguyen, B. Vidal, J. Loriau, C. Couzigou, M. Dumay, J. Carlet","doi":"10.1136/QSHC.2010.041624.5","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.5","url":null,"abstract":"Context and objectives The rates of methicillin resistant staphylococcus aureus (MRSA) in France has been over 25% from 2000 to 2007, higher than in most European countries in the earss surveillance program. Hospital acquired bacteremias due to MRSA are one of the best markers of the clinical impact of cross-transmission. The strategies designed to prevent hospital diffusion of MRSA are centered on isolation precautions and antibiotic stewardship. We implemented a program at the hospital level, combining these two approaches, and we measured its impact on the incidence of the patients acquiring colonisation or bacteraemia during their hospital stay since 2000. In our hospital before 2000, the infectious disease team and the infection control unit had failed to reduce hospital acquired MRSA carriage and bacteraemia despite continuous actions of antibiotic prescription counselling, MRSA detection and isolation of carriers. Our hospital had 450 acute beds in 2000 progressively rising to 600 in 2008 due to government driven hospital restructuring plans in the parisian area. All the medical and surgical specialities are available except neurosurgery. From 2000 to 2003, the following measures were successively implemented: hand disinfection with alcohol based hand rubs, control and counselling for the use of certain antibiotic classes, assessment of the care providers compliance to isolation measures, as well as feed back to care providers of the information regarding the principal indicators collected at the hospital level, and in the ICU and several high risk units, active screening and decontamination of the MRSA carriers. The impact of this program was assessed by measuring the incidence of both hospital acquired MRSA carriage and bacteremias for 1000 patient-days, in those patients hospitalised for more than 24 h. Results The compliance of the personnel to isolation measures increased over years, as soon as audits were implemented. The use of alcohol based hand rubs was implemented in the entire hospital over 2 years and their consumption then increased progressively from 7 l per 1000 patient-days. The use of quinolones and third generation cephalosporins decreased by around 25%. the annual incidence of hospital acquired MRSA colonisation and bacteremias per 1000 patient-days decreased by 61% and 88% respectively. The ratio between ‘hospital acquired’ and ‘imported from the community’ MRSA carriers decreased from 1.1 in 2000 to 0.15 in 2009. Discussion As we used a ‘before-after’ design, the decrease of hospital acquired infections we observed may have been due to other innovations than the program itself, and particularly to the reduction in the imported cases. Also, the active screening of the carriers was not performed in all the units, which may have led to an overestimation of the number of the hospital acquired cases. However, the same strategy was used throughout the program and the same results were observed within the ICU were active scre","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":"82374744","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":"134 Clinical impact of a manual for investigations in an emergency department","authors":"Steinmetz Jean-Philippe, Bilbault Pascal, B. Christophe, Gicquel-Schlemmer Barbara, Geronimus Claude, K. Pierre, Roedlich Marie-Noëlle, V. Francis, Rohr Serge, Kopferschmitt Jacques","doi":"10.1136/qshc.2010.041624.88","DOIUrl":"https://doi.org/10.1136/qshc.2010.041624.88","url":null,"abstract":"Context An evaluation of the relevance of investigations prescribed in the adult emergency department is in place since 2005 in our hospital. In a general context where our Hospital was considered as one of the most prescribing University Hospital in terms of biology and imaging, it became necessary to undertake such an evaluation, particularly in the emergency department where numerous participants practice in different ways. The objectives: define the reasons for further investigations in various clinical situations, build a number of indicators in order to evaluate how the good medical practice rules are applied, evaluate the relevance for further investigations with elaborated references, improve quality and safety of patients care (waiting time, reduction or elimination of risks due to some investigations, useless investigations, unjustified irradiation). Schedule A schedule in three stages was put in place: writing of a manual for biology and imaging investigations. This booklet was built in a multidisciplinary way in association with all the prescribers (specialists and consultants) involved in the Emergency department activity. At first in 2005, fifty-eight surgical clinical situations were identified and the protocols determined. In the second edition of the manual in 2008, 40 additional protocols were defined mainly for non surgical matters. The development of this manual was based on national and international references validated and updated, but also on the expertise of all the local teams; how to build and choose indicators to allow evaluation of the rules of good medical practice described in the manual was defined and regularly revised; the relevance of the way of practice is evaluated with specific criteria following a predefined agenda. Assessment is organised and carried out by identified colleagues in different fields: pre-operative tests, walk-in traumatology, specific clinical presentations, etc. The manual was validated by the Hospital Medical Committee and has been widely distributed (on paper or online). Several follow-up indicators are in place: by themes or specific clinical situations in coordination with the managing departments. Results Following up the results was done over the past 4 years. For example: lipase is now asked instead of amylase, 60% less plain abdomens, 14% less ankles x-ray, no more ribcage x-ray neither nasal bone x-ray. One of the specific pathological situation evaluated was acute appendicitis: the pre-operative tests were reduced: from 30% to 11% for the standard biology, from 94% to 30% for blood group, from 48% to 4% for ECG requests and from 32% to 3% for the chest x-ray. Discussion To facilitate the use of the manual, several clinical guidelines and protocols have been drawn up and evaluated on a prospective way. The program helped to open up the specialities and introduced a new evaluation culture amongst the teams. The future goals are to improve political support and everybody's involvemen","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":"76616145","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":"051 Pain management in home care","authors":"Chappuis Viviane","doi":"10.1136/qshc.2010.041624.86","DOIUrl":"https://doi.org/10.1136/qshc.2010.041624.86","url":null,"abstract":"Background and objective Pain management in home care patients is a priority. The General Practitioner (GP) prescribes treatment but is not always sufficiently trained in the management of serious disease. Home healthcare professionals rate pain intensity. Specific forms in the patient's file enable assessment of patients with normal or impaired communication abilities. Our objective was to analyse the results obtained for pain assessment and treatment in a sample of patients receiving home care. Programme We performed a retrospective review of 35 random files for patients recently admitted to home care in order to determine the percentage of patients assessed for pain on the day of their admission and the analgesic treatment they received. We also reviewed reassessments of pain and prescriptions during home care, the support provided to the prescribing GPs by the coordinating physicians trained in algology, and pain assessment and analgesic prescription on the last day of home care. Results Sixty per cent of the patients newly admitted to home care were receiving palliative care and 17% curative care; 46% were oncology patients and 20% geriatric patients; 65% had a Karnovski index ≤40. Mean age was 73 years. Seventy four per cent of the patients were assessed for pain on the day of their admission using a visual analogue scale (VAS) (77%) or Algoplus (23%). Seventy seven were taking analgesics. Pain was persistent in 35%. All patients suffering from pain were treated with level 1 to 3 analgesics, but level 3 analgesics were never administered by the parenteral route. During the care period, pain was assessed on average once daily in patients suffering from pain, every 2 days in patients not in pain at admission, and every 3 days in patients who were not assessed at admission. Analgesic treatment was revised in 51% of the patients. Dose was readjusted in 82% of the patients in pain. The coordinating physician provided the GP with advice on readjustment in 59% of patients in pain. Analgesic treatment was not modified in 18% of patients in pain. On the last day of home care, pain was present in only 9% of patients (VAS (57%) or Algoplus (43%)); 89% of these patients were taking analgesics; 49% were on level 3 analgesics (1/3 in SAP or patient-controlled analgesia) compared to 23% upon admission. Forty two per cent of the patients died during home care and 35% were re-hospitalised for a mean duration of 51 days. Discussion and conclusion This study highlights the value of pain assessment on admission to home care and regularly throughout home care. Carers should regularly be made aware of the need for such assessment. Since the patient is at home, the physicians involved (GP, specialist, coordinating physician) must be informed of assessment outcomes. Carers are requested to phone the results to the GP as soon as the scores show that the patient is in pain. However, some GPs are still insufficiently trained in pain assessment and treatment. The coor","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":"76809982","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":"252 Assessment of emergency care of patients with ST+ Acute Coronary Syndromes","authors":"S. Charpentier, S. Grolleau, C. Sagnes-Raffy, G. Foucart, J. Ducassé","doi":"10.1136/QSHC.2010.041616.9","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041616.9","url":null,"abstract":"Objectives and Background The objective was to evaluate the emergency care of patients presenting with ST+ACS in the context of the recommendations of the French Societies of Emergency Medicine and Cardiology with a view to reducing ACS morbi-mortality: the use of the SAMU call center; antiplatelet treatment; admission in cardiology intensive care unit (CICU), reperfusion therapy rate>75%; delay from first medical contact to electrocardiogram (ECG) interpretation <10 min; to angioplasty (door to balloon) <90 min; to thrombolysis (door to needle) <30 min. Program A multicentre, longitudinal, multidisciplinary register covering the Department. Every patient seen by an emergency physician for an ST+ACS within 12 h either by prehospital, by a mobile intensive care unit (MICU) or presenting themselves at the public and private emergency rooms (ER) was included and followed for one month. The data regarding treatments and delays and in hospital mortality were recorded in prehospital, in ER or after transfer to CICU. The Haute Autorité de Santé clinical practice indicators were used and descriptive statistical analyses carried out with the delays expressed as medians (interquartile). The main measures were compared between the patients arriving via the MICU and those presenting ER, using the chi-square (qualitative variables) and the Mann–Whitney test (quantitative variables). Results Between January 2007 and June 2008, 417 patients were included (mean age 62; sex ratio 3.1), with 80% by the MICU after calling the SAMU. The completion rate was 96%. The time between the onset of pain and first medical contact was 97 min (54–180), that is, <3 h for 75% of the patients. An ECG was done in 7 min (5–13). The rate of admission to the CICU was 98% with a delay of 89 min (60–136), with 9% being under 45 min. The antiplatelet therapy (aspirin and clopidogrel) rate was 85%. The rate of reperfusion was 96%, of which 65% by primary angioplasty and 32% by thrombolytic therapy. The median door to balloon delay was 136 min (97–208) and door to needle delay 20 min (10–24). The in-hospital mortality rate was 4.3%. MICU and ER comparison: reperfusion rate was ≥95%, with no significant difference reported (respectively, 95.5% vs 97.5%, p=0.39). MICU patients had significantly shorter treatment delays: door to balloon (122 min vs 196, p=0.0001), door to needle (20 min vs 28, p=0.001), door to ECG (6 min vs 11, p=0.001). Antiplatelet agents prescription was high, with no reported significant difference (85% vs 86%, p=0.94). Discussion The register enables to objectively compare the emergency systems using the relevant medical indicators. The results are in agreement with the standard recommendations, with the exception of the time of door to balloon, which should be improved. The longer waiting times seen for the independent arrivals in Emergency confirms, in the case of chest pain, the necessity of a recourse to the SAMU call centre number 15 in the first instance. Concl","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":"78091490","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":"129 Management of destitute homeless patients in the emergency department of Toulouse University Hospital","authors":"P. Estecahandy, V. Barbé","doi":"10.1136/qshc.2010.041632.17","DOIUrl":"https://doi.org/10.1136/qshc.2010.041632.17","url":null,"abstract":"Background and Objectives People with poor living conditions have a poor state of health, with a high rate of early deaths and a life expectancy that may be 30–35 years shorter than that of the general population. Their main access to health care is via the hospital emergency department (ED); they undergo repeated admissions but treatment is not really effective. In Toulouse, the number of homeless people who are ill is about 1000 and the estimated number of ED admissions is 1 or 2 per day. Suitable health facilities are available for these people but hospital staff are little aware of them. A health strategy involving both medical and social services thus needs to be developed and implemented. The objective of our study was to improve the follow up of destitute patients after discharge from ED by introducing a coordinated approach involving hospital staff and social workers within a network and by guaranteeing clear visibility of medical information. Programme In 2008, 90 patients were classified as destitute. We organised ad-hoc coordination tools, a central medical filing system, and regular multidisciplinary meetings between ED staff and the network. Assessment of the programme was based on: (1) a survey of ED staff's awareness of the health facilities for the destitute, (2) a review of medical files, (3) monitoring of coordination tools, (4) compliance with the holding of multidisciplinary meetings. Results Between 2007 and 2008, we observed a 50% improvement in the awareness of ED staff of health facilities for the destitute. However, although two-thirds of the staff were better informed, they still did not make efficient use of the facilities available. Only 30% of the staff used the coordination tools, revealing room for much improvement. On the other hand, medical information was correctly centralised. Admission to ED was noted in 100% of patient medical files and 80% of the ED reports could be found in the file. The three planned multidisciplinary meetings devoted to file review took place and led to a joint medical-social health strategy for 90% of patients with repeated admissions. Cooperation between the ED and social facilities made for more fluid access to healthcare by these patients. After 1 year of network operation, 20% of destitute people were being looked after by an appropriate organism and were accessing healthcare via a general practitioner. Discussion and Conclusion Our study has highlighted the part that the hospital ED can play in the management of destitute homeless patients and the need to implement joint actions with social and other health facilities within a healthcare network. This ‘health network for the destitute’ provides expertise and support that can be immediately activated by ED staff. Use of the computerised personal medical file, when nationally available, should become routine when the homeless are admitted to the ED. Contexte et objectifs Les personnes en situation de grande précarité ont un état de ","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":"77726110","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":"232 Impact of clinical guidelines in France","authors":"F. Vendittelli, O. Rivière, C. Crenn-Hébert","doi":"10.1136/qshc.2010.041632.35","DOIUrl":"https://doi.org/10.1136/qshc.2010.041632.35","url":null,"abstract":"Context and Objectives Clinical practice guidelines (CPGs) covering the perinatal period are published regularly by French College of Gynaecologists and Obstetricians as well as by the National Authority for Health. Nonetheless, assessment of the impact of these guidelines is not routinely considered in France. The objective of this work is to describe the trends in practices before and after CPGs are issued in France. Programme Between 1994 and 2005, Audipog received data from 209 public and private maternity units for a database covering 247 807 pregnancies. We constructed a random subsample for each year by including only the births occurring during a single month for each maternity ward. Our study analyzes therefore 103 141 pregnancies and 104 454 births. Because of the voluntary nature of participation in Audipog, its distribution of maternity units according to legal status and region differed from that of France as a whole, a difference that must be taken into account in the analysis. Eight sets of national CPGs were analysed in this study. Results The 1998 CPG had little impact, for the rate of infants weighing <1500 g born in Level III units has remained stable since 1998, at around 70%. The rate of babies born before 33 weeks of gestation in a Level III facility in 2005 has returned to the rate in 1994 (53%). The caesarean rate in nulliparas has remained stable, at around 20% (RPC2000). The rate of antenatal corticosteroid therapy among the births before 33 weeks rose from 42% to 50% between 2000 and 2005 (RPC 2002). Breast-feeding at discharge has been rising slowly (51% in 2000 and 58% in 2005)(RPC 2002). Smoking among pregnant women has been falling continually but slowly since 1994 (RPC 2003). Active management of the third stage of labour rose from 1994 (6%) to 2004 (30%) but remained at 31% in 2005 (RPC 2004). Early discharge after delivery has increased since 1994, independently of the CPG in 2004. The episiotomy rate has been dropping slowly since 1994 (55% in 1994 and 40% in 2005)(RPC 2005). Discussion and Conclusion Practices were modified very little by CPGs, except for those concerning antenatal corticosteroid therapy, but practices often changed before the issuance of the guidelines. Research to determine how to optimise the dissemination of CPGs would be desirable. Contextes, objectifs Des recommandations de pratiques cliniques (RPC) sont régulièrement publiées par le Collège des Gynécologues Obstétriciens Français ainsi que par la Haute Autorité de Santé en périnatalité. Pour autant, l'étude de l'impact de ces recommandations n'est pas systématiquement envisagé, en France. L'objectif de ce travail est de décrire l'évolution des pratiques avant et/ou après la mise en place de RPC, en France. Porgramme L'Audipog a reçu, entre 1994-2005, des données de 209 maternités publiques ou privées, conduisant à un fichier de 247807 grossesses. Nous avons constitué pour chaque année, un sous échantillon, par ti","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":"74257321","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}