Quality and Safety in Health Care最新文献

{"title":"168 Impact of morbidity and mortality conferences on the incidence of adverse events in an intensive care unit (ICU)","authors":"B. Misset, C. Bruel, S. Touati, M. Dumain, M. Moulard, F. Philippart, M. Garrouste-Orgeas, J. Carlet","doi":"10.1136/QSHC.2010.041624.22","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.22","url":null,"abstract":"Context and objectives Mortality is the principal indicator used to assess the performance of Intensive Care Units (ICU), through the ratio between observed and predicted mortality with the Simplified Acute Physiology Score II (SAPS II) at admission, called Standardised Mortality Ratio (SMR). The differences in case-mix make it difficult to compare two ICUs with the SMR only, and the progressive improvement of the prognosis due to medical progress make historical comparisons difficult to perform within a single ICU. The incidence of several well defined and supposedly avoidable adverse events is another marker of quality of care. The aim of the study was to assess the impact of morbidity and mortality conferences (MMC) on adverse events in our ICU. Program The follow-up of several adverse events has been performed prospectively in our ICU since 2000, on patients with a ICU length of stay over 48 h. We implemented MMC in 2003 according to methods similar to the ones currently promoted by the French Authority for Health. The files of all the patients deceased in the ICU are analysed. The meetings take place every 6 weeks. The intensive care physicians and the interns are invited to participate. The conclusions of the sessions are recorded in an electronic database. The cases in which the treatment was considered inadequate or associated with an adverse event led to adjustment of existing procedures. The adverse events which were used as indicators in the entire population were accidental removal of the tracheal tubes and secondary pneumothoraces, on an electronic database, prospectively completed for all patients hospitalised for more than 48 h, except during the summer months of vacations. Results Among 486 deceased patients, 406 stays were analysed (83%). The therapy was considered inadequate or associated with an adverse event in 61 patients (15%). The adverse event played a significant role in the death in 22 patients (6%) and was considered avoidable in 21 (6%). It both played a significant role and was considered avoidable in 11 patients (3%). The principal adverse events in the patients discussed during a MMC were pneumothorax (n=13), haemorrhage (n=9), accidental removal or difficult placement of tracheal tube (n=9), cardiac arrest (n=8) and drug allergy or overdose (n=8). During the study period, in the entire admitted population, the incidence of accidental removal or difficult placement of the tracheal tube decreased progressively from 14% to 8% and the incidence of secondary pneumothoraces from 4% to 1%. The ratio between observed and predicted mortality decreased from 1.05 to 0.6. Discussion The causal relationship between MMC implementation and the decrease in adverse events is likely. However, other aspects of the quality culture of our ICU may have played a role. The main technical limitations of our study were the absence of measurement of the compliance to the procedures, and the impossibility to measure the adverse events exhaust","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":"74623779","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":"178 RUN-FC: network of neurological emergencies in Franche Comté","authors":"L. Champonnois, E. M. de Bustos, F. Vuillier, P. Montiel, R. Allibert, D. Chavot, T. Moulin","doi":"10.1136/QSHC.2010.041608.11","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041608.11","url":null,"abstract":"Stroke is the leading cause of disability, the second leading cause of dementia and the third leading cause of death in France. Head injuries resulting from road accidents are also on the list of public health priorities defined by the Ministry of Health. The emeRgency neUrology Network in Franche-Comté (RUN-FC) is a regional structure, designed to meet the everyday needs of emergency neurology patients (stroke and head injuries) by combining the efforts of all those involved in patient care. Besançon University Hospital is the only hospital in the region to house a neurosurgery department and a specialist unit for neurovascular pathology. The RUN network has developed a range of telemedicine tools, enabling neurologists, neurosurgeons and radiologists at the university hospital to give medical advise to emergency physicians in 11 other hospitals in the Franche-Comté region where on-site specialists are not available. Image transfers (CT, MRI), videoconferencing and electronic patient medical records are the telemedicine tools which enable information to be exchanged in real time, improving the reliability and accuracy of the diagnosis. Telemedicine allows an accurate, standardised neurological examination to be performed remotely, and enables a diagnosis and therapeutic decision to be made. Furthermore, a neurologist from Besançon University Hospital visits the hospital in Pontarlier once a week. This special collaboration has enabled 44% more strokes and TIAs to be diagnosed. In parallel, the RUN network monitors stroke victims hospitalised in Besançon for five years following discharge. A nurse from the network reviews every electronic patient file, makes regular contact with every patient, listens, gives advice and suggests an appointment with a neurologist if a problem is detected. The patient's general practitioner is kept informed at all times. Between 2002 and 2008, 8000 images were transferred via the RUN-FC server. The use of telemedicine has reduced the number of patient transfers by 50%. These avoidable transfers have proven detrimental to the patient, or at best, costly and of little avail. During the first five years, an estimated 3.5 million euros were saved (in transport costs). Savings made over the following years have been even greater due to the large increase in the number of patients receiving on-site treatment via teleconsultation. Between 2003 and October 2009, 79 patients received thrombolytic treatment at Besançon University Hospital (35% of which after transfer), and 48 patients were thrombolysed in the peripheral hospitals. A retrospective study on 76 patients shows that, in the peripheral hospitals, the time delay before initiating thrombolysis is shorter, and the treatment at least as effective, as at the university hospital. Since 2003, 2600 stroke victims have been followed up within the network. 20% of patients have required action to be taken by the network at least once. The survival rate of discharged pat","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":"79158067","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":"043 Effect of a patient education programme on quality of life in patients with chronic heart failure","authors":"M. Séronde, M. Nicolas, V Descotes-Genon, R. Chopard, J. Dutheil, F. Briand, Y. Bernard, F. Schiele","doi":"10.1136/QSHC.2010.041616.17","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041616.17","url":null,"abstract":"Background and Objectives Heart failure is a major public health issue in France. To deal with the complex management of this disease, therapeutic patient education (TPE) programmes have been developed over recent years which focus on optimising patient autonomy and self-management. Several studies have shown that TPE programmes help reduce the number of hospital readmissions and the length of hospital stay, as well as the overall costs associated with the disease. In 2004, a TPE centre for patients with chronic heart failure (CETIC) was established in the cardiology outpatients department of Besançon university hospital. It is staffed by a multidisciplinary team. The aim of this study was to evaluate the efficacy of TPE in improving patients' quality of life. Programme Participation in TPE was on an outpatient basis and started at least 1 month after discharge. Individual and group sessions were held by a multidisciplinary team comprising a nurse, a cardiologist and a dietician. During the group sessions, four themes were discussed: chronic heart failure and warning signs, treatment; low-salt diet and physical activity. Patients were seen at the start of the programme, then once every month for 4 months, and finally, 6 months after the end of the programme. The main endpoint was quality of life as measured by the Minnesota questionnaire at the start and 6 months after the end of the programme. Results A significant improvement was observed in the quality of life of patients with chronic heart failure who participated in TPE. The overall Minnesota score decreased from 37.6±24 before the programme to 26±18 after the programme (p<0.0001), the physical dimension score decreased from 17 to 12 (p<0.0001) and the emotional dimension from 6 to 4 (p<0.0001). The clearcut improvement in quality of life, especially for the physical dimension, was mainly due to a reduction in dyspnea, asthenia and in difficulties with activities of daily life, walking and climbing stairs. This improvement in quality of life should help contribute towards reducing further episodes of decompensation and subsequent readmission to hospital. Discussion and Conclusion Despite progress in the management of chronic heart failure, the prognosis is unfavourable, with a mortality rate of about 50% at 1 year for the most advanced stages of the disease. In general, hospital admissions increase as the disease progresses. One patient in two is readmitted to hospital within 1 year of decompensation. Chronic heart failure is the main cause of hospital admissions in patients aged over 65 years. Half of the admissions are due to avoidable causes, such as low compliance with treatment and lifestyle guidelines, or inappropriate follow-up. Several studies have shown that specific interventions on modifiable risk factors can help reduce the number of decompensation episodes and thus hospital readmissions. TPE programmes help improve quality of life, functional status, tolerance for physical acti","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":"80430457","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":"023 Antibiotic prophylaxis in orthopaedic surgery: audit findings and improvement actions","authors":"H. Bonfait, C. Delaunay, E. de Thomasson, O. Charrois","doi":"10.1136/QSHC.2010.041624.32","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.32","url":null,"abstract":"Background and objectives Antibiotic prophylaxis is a major tool for the safe implantation of any medical device. The ‘Société Française d'Anesthésie et Réanimation’ (SFAR) produced the first French guidelines for antibiotic prophylaxis back in 1992 but, since then, several practice surveys have shown that compliance is low. Our objective was to develop recommendations for improving compliance. Programme We reviewed 153 analytical questionnaires that had been completed by all the orthopaedic surgeons who had reported a risk event related to antibiotic prophylaxis during their 2008 ‘accreditation programme’. Reporting was to Orthorisq, a certified organisation. The questions explored four fields directly related to the circumstances and professional conditions prompting the report: (1) characteristics of the institution's antibiotic prophylaxis protocol, (2) circumstances leading up to the discovery of the event, (3) search for human and organisational causes, and (4) recovery actions, if carried out. The questionnaires reflected the experience of orthopaedic surgeons, most of whom were discovering risk management procedures for the first time. Results An antibiotic prophylaxis protocol existed in nearly all institutions, but was not available at the appropriate site in 15% of cases. Most orthopaedic surgeons considered that the protocol was suited to their practice, but over 10% did not know its exact content. Most reports were the result of an immediate peri-operative dysfunctional event that the surgeon had discovered by chance. Most risk events were discovered after skin incision. A systematic prospective (use of checklist) or retrospective (audit) analysis was very seldom performed. The causes of the event were material (28%), human (92%) and/or organisational (50%). The main cause of inappropriate antibiotic prophylaxis was ‘omission of administration through negligence or inadvertence’ (56% of reports). Overall, 65% of surgeons reported a low-grade recovery procedure, but only 20% of them were able to reinitiate an appropriate antibiotic prophylaxis procedure. Discussion and conclusion Our results have highlighted the risks related to the cross-disciplinary and cross-professional (‘transversal’) aspects of the prescription and administration of antibiotic prophylaxis, thus raising the issue of the practitioner's responsibility in the case of a nosocomial infection. Because of the high rate of omissions, 40% of surgeons spontaneously suggested routine use of a checklist. The following improvement axes were proposed: (1) updating protocols for antibiotic prophylaxis by indicating ‘who does what?’; (2) routine checks of protocol knowledge by all new arrivals (resident practitioners, temporary staff, and locums); (3) involving patients in data collection for their medical records; (4) encouraging use of a checklist in line with WHO and HAS recommendations. These conclusions should be taken into account when SFAR next updates its guidelines","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":"84862182","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":"062 Treatement of relapses of multiple sclerosis at home: improvement in quality of life and reduction of cost. Experience of the network in Lorraine LORSEP","authors":"D. Marc, Lanotte Livia, Villemin Yolande, Busch Emmanuelle","doi":"10.1136/QSHC.2010.041624.87","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.87","url":null,"abstract":"Nowadays, MS relapses are treated with high-dose intravenous Methylprednisolone over a three-day period. This treatment is usually received at the hospital but can be administered at home. The purpose of this study conducted between 26 November 2005 and 29 January 2008 is to determine the economic impact of a home-based treatment by a MS network: LORSEP in the case, as well as the impact on the patient's quality of life. Eligible patients belonged to the network, needed treatment for a relapse and showed no contraindication for receiving this treatment at home. A questionnaire was used to measure patient satisfaction. The economic impact was measured via direct and indirect costs. Two hundred sixty women and 90 men were treated, for an overall of 357 treatments. 53.1% of patients received the first treatment at home. Community-based neurologists referred 54% of patients, hospital-based neurologists 46%. Eighty nine per cent of patients were satisfied and 96% wished to renew the treatment at home. Some minor side effects were observed in 24.4% of the cases, moderate ones in 2.4%. Cost of these treatments amounted to 118 512 euros. The health economy amounted to 124 251 euros for the Lorraine region, and 8471 kms avoided for the patients. The home-based treatment is safe, efficient and appreciated by the patients. It shows advantages for the patients, as well as for doctors and society. MS networks are valuable partners in developing cost-effective treatments. Les poussées de Sclérose en plaques (SEP) sont actuellement traitées par fortes doses de méthylprednisolone administrées en intraveineux sur trois à cinq jours. Ce traitement, habituellement réalisé en hospitalisation, peut se faire à domicile. Le but de l' étude menée du 26/11/05 au 29/01/2008, est de démontrer l'impact économique et sur la qualité de vie du patient de la réalisation des perfusions à domicile organisée par un réseau de santé: le LORSEP. Les patients éligibles étaient ceux qui présentaient une poussée nécessitant un traitement et ne présentaient pas de contre-indication médicale à la réalisation de ce traitement à domicile. La satisfaction du patient était mesurée grâce à un questionnaire. L'étude médico-économique consiste en la mesure des coûts directs et indirects. 357 cures ont été réalisées chez 260 femmes et 90 hommes. 53;1% des patients ont reçu la première perfusion en hospitalisation de jour. Les patients étaient issus des consultations des neurologues libéraux pour 54% et hospitaliers pour 46% d'entre eux. 89% des patients se sont dits satisfaits et 96% ont souhaité renouveler ce traitement à domicile. Des effets secondaires mineurs ont été constatés pour 24,4% des cures et des effets secondaires modérés pour 2,4% d'entre elles. Le coût de ces perfusions à domicile a été de 118 512 euros. L'économie de santé a été de 124 251 euros pour la Lorraine, avec 8471 kms évités pour les patients. La procédure est","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":"74781591","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":"229 Evaluating the clinical impact of quality improvement measures in patients with type 2 diabetes in general practice: repeat audit or cohort follow-up?","authors":"A. Moulin, L. Pazart, C. Elsass, C. Vidal","doi":"10.1136/QSHC.2010.041632.34","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041632.34","url":null,"abstract":"Background and Objectives In 2005, the six general practitioners (GPs) in our health centre attended mostly by vulnerable patients began an audit of the management of patients with type 2 diabetes. Our objective was to compare assessment of the impact of our improvement plan on glycated haemoglobin (HbA1c) values using the results obtained (i) during the three rounds of the audit, (ii) during follow-up of the cohort of the first round. Programme The improvement plan used computer reminders. Each GP could create an individual patient by patient system for decision support. Each round of the audit concerned 50 patients with type 2 diabetes. The first sample (in 2005) was made up of patients who had attended the centre during a 3-month period. They were identified from paper diaries and included in chronological order. Patients forming the two following samples were randomly selected from the updated electronic register of all patients with type 2 diabetes. Results The results for 36 patients in the 2005 sample were analysed in 2008. The audits showed a statistically significant improvement during this period in compliance with six criteria in the guidance provided by HAS. Although the percentage of orders for an HbA1c test of going back less than 4 months increased, albeit not significantly (78% vs 82%), tests were actually carried out less often (74% vs 66%). A comparison of the mean values for the first HbA1c tests in 2005 and the last tests in 2008 revealed a very nearly significant difference for the audits (8.05 (n=41) vs 7.19 (n=36), p=0.05) but no difference on cohort follow-up (n=30; 8.18 vs 8.22 p=0.92). The percentage of patients with a first HbA1c value of less than 7% was significantly lower in 2005 than in 2008 for the audits (30% vs 55%, p=0.02) but stable for the cohort (27% vs 33%, p=0.57). Discussion and Conclusion Overall, there were improvements in practice that were maintained over time. However, results for HbA1c did not agree for the two assessment methods (audits vs cohort). An improvement was recorded in the audits whereas results were stable for the cohort. The sampling fraction was high (between a quarter to a third of the whole population) in each audit round, thus limiting selection bias due to different sampling techniques in 2005 and 2008. However, a substantial annual turnover of the diabetic population of the centre led to a change in the reference population during repeated sampling. This bias would require a more detailed analysis of the comparability of samples, in particular in terms of disease characteristics (history, severity of diabetes). This is not usually done in an audit. The cohort approach appears more reliable but is hampered by the number of drop-outs and the natural course of the disease when impact is assessed over several years. In conclusion, computer management and the use of reminders improved practices and compliance with HAS guidance in a primary care setting. However, our quality initiative h","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":"76377913","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":"094 Prevention of tunnelled catheter-related bacteraemia: is the solution antibiotic, heparin or citrate lock therapy associated with universal hygiene recommendations? follow-up over three consecutive periods (1999–2008)","authors":"A. Guerraoui, G. Laroussinie, Plaidy Agnès, Roussel Clair, Remford Sandrine, Richard Christine, Colette Dubord, Pfennig Sandrine","doi":"10.1136/qshc.2010.041616.4","DOIUrl":"https://doi.org/10.1136/qshc.2010.041616.4","url":null,"abstract":"Background and objective Catheter-related bacteraemia (CRB) is associated with an increased risk of morbidity and mortality in haemodialysis patients and accounts for 50 to 70% of catheter removals. Antibiotic lock therapy can prevent CRB in these patients but may have side-effects such as loss of hearing or acquisition of antibiotic resistance. The aim of this study was to evaluate CRB incidence over three consecutive periods using different antibiotic locks. Programme Setting and participants All adults treated by haemodialysis through a tunnelled catheter (March 1, 1999–December 31, 2008) (102 patients, 144 tunnelled catheters, 31 536 catheter-days). Quality improvement plan Universal hygiene rules, setting up of a follow-up registry, antimicrobial locks: heparin plus gentamicin (Period 1, March 1999—June 2000); heparin alone (Period 2, July 2000—December 2004); citrate (Period 3, January 2005—December 2008). Measures Repeated observations of CRB, catheter colonisation and orifice infection, analysis using simple descriptive statistics, χ2 tests. Results Period 1: CRB incidence was 1.96 per 1000 catheters-days in 1999 and 0.29 in 2000 (p<0.005). Emergence of multiresistant staphylococcus epidermidis (MRSE) was observed and the gentamicin lock was abandoned. The MRSE rate decreased within the next 18 months (p<0.005). Period 2: CRB incidence increased from 0.39 per 1000 catheter-days in 2001 to 2.03 in 2002. In 2003, an audit of hygiene practices revealed non compliance with universal hygiene guidelines by the youngest nurses. After intensive nurse training, CRB incidence decreased to 0.76 per 1000 catheter-days in 2003 and to 0.63 in 2004. Period 3: CRB incidence decreased to 0.28, 0.37, 0.63, and 0 per 1000 catheter-days in 2005, 2006, 2007 and 2008, respectively. No adverse events and no catheter thrombosis were observed. Discussion and conclusions A gentamicin lock was associated with a highly significant reduction in CRB incidence but also with a highly significant emergence of bacterial resistance. Heparin alone was associated with a decrease in resistance but a higher CRB incidence despite reinforced hygiene rules. In units such as dialysis centres, gestures are repetitive and drifts in practices are quick to occur. Regular assessment is therefore essential. Since January 2003, a hygiene nurse carries out 6-monthly audits of our quality procedures in clinical and hygiene practice. The follow-up registry we have set up enables periodical re-evaluation of our procedures and the taking of corrective actions. Contexte et objectif L'infection reste la complication la plus fréquente des cathéters (KT) d'hémodialyse. Elle représente 50 à 70% des motifs d'ablations des KT. Le risque relatif de bactériémie est de 7,64 (fistule, RR =1). En 1999 nous avons constaté un taux élevé d'infection secondaire aux KT. Programme Un audit initial a été réalisé pendant 6 mois (de mars 1999 à septembre 1999) qui a confirmé un taux hautement éle","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":"74261326","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":"046 Management of osteoporosis after fracture. Impact of a multidisciplinary approach","authors":"N. Koenig, C. Villoutreix, F. Roux, S. Durieux, J. Cohen-Solal, P. Bréville, Y. Bézie, P. Jouffroy, E. Brière, Albane Lumbroso, Rajzbaum Gérald","doi":"10.1136/qshc.2010.041624.96","DOIUrl":"https://doi.org/10.1136/qshc.2010.041624.96","url":null,"abstract":"Objectives Osteoporosis with fractures is a serious condition that too often receives inadequate attention, as indicated by many studies documenting low rates of osteoporosis evaluation and treatment in fracture patients. Since 2005, a multidisciplinary team at the Saint-Joseph Hospital, Paris, France, has been working on strategies for improving the detection and medical treatment of osteoporosis with fractures. This work led to the implementation of a clinical practice evaluation program that has been validated by the French High Health Authority. Here, our objective was to determine whether this program improved clinical practice patterns. Patients and methods We identified women older than 45 years of age who were managed in the emergency room and/or admitted for a fracture at the wrist, proximal humerus, hip, or spine. These patients were managed according to a protocol that complied with good clinical practice guidelines. Their data were recorded in a specific file and analysed at regular intervals by a multidisciplinary study group composed of rheumatologists, orthopaedic surgeons, geriatrists, and emergency physicians. Practice patterns were assessed based on the most widely used criteria, namely, the proportions of patients who underwent bone mineral density measurement and/or received long-term treatment after a low-energy fracture consistent with osteoporosis. Results Between January 1, 2006, and December 31, 2008, we identified 1229 patients, among whom 718 were admitted. During the study period, the rate of bone mineral density measurement increased from 54% to 87% among wrist fracture patients and from 38% to 71% among patients with proximal humeral fractures. The rate of long-term treatment initiation increased from 8% to 53% among hip fracture patients and from 40% to 77% among vertebral fracture patients. The additional cost associated with the evaluation program was about 20,000 Euro per year. Conclusion Our multidisciplinary evaluation program improved osteoporosis management in women older than 45 years who were seen for fractures. The challenge now is to sustain the success of the program and to extend it to general practitioners and other physicians involved with osteoporosis. Objectifs L'ostéoporose fracturaire est une maladie grave, trop souvent négligée, comme en témoignent les nombreuses publications sur le déficit de la prise en charge de cette maladie au décours d'une fracture. Une réflexion pluridisciplinaire sur l'amélioration du dépistage et du traitement médical de l'ostéoporose fracturaire s'est progressivement développée depuis 2005 au sein du Groupe hospitalier Paris Saint-Joseph. Elle a abouti à l'instauration d'une démarche d’évaluation des pratiques professionnelles validée par la HAS. Le but de ce travail était de montrer l'amélioration des pratiques médicales ainsi obtenue. Patientes et méthode Les patientes de plus de 45 ans venues au service d'accueil des urgences et/ou hospitalisées","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":"77369900","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":"277 Management of sleeping disorders: the Morphée network","authors":"Royant-Parola Sylvie, Hart Sarah, Colas Des Francs Claire, Dagneaux Sylvain, Escourrou Pierre","doi":"10.1136/QSHC.2010.041624.85","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.85","url":null,"abstract":"Context Sleep disorders are a major cause of consultation in France and lead to long term and inappropriate prescription of sleeping pills. Managing sleep disorders in primary care in France is difficult. GPs lack basic training in diagnosing and treating insomnia, access to secondary care is slow, with clinic delays of 3–6 months, and despite the recommendations of the national insomnia guidelines, access to behavioural therapy for insomnia is limited. Programme The Morphee network is a regional health network dedicated to improving care for sleep disorders. For over 6 years, Morphée has been working to improve care in sleep disorders, focussing on identifying the optimal care pathway for each individual patient, organising behavioural therapy groups as an alternative to sleeping pills in primary insomnia, training health professionals and educating the public. The care pathway assessment uses a sleep questionnaire, analysed by the medical coordinators which, for most patients, identifies the sleep disorder and the optimal care pathway. Difficult cases are seen by a consulting GP (trained by the network in the analysis and triage of sleep disorders) who organises the care pathway with the assistance of the medical coordinators. Patients are directed either to a three session behavioural therapy group, to a sleep specialist for a consultation or an investigation, or finally, in the case of a sleep disorder secondary to a medical or psychiatric problem, to their own GP or psychiatrist. Résultats 226 health professionals are members of Morphée. 3363 patients are followed by the network with a mean age of 52 years (2055<55 years, 1089 56–70 years, 463>75 years). 64% have sleep apnea, 16% insomnia, 8% hypersomnia and 5% a co-morbid sleep disorder linked to an underlying psychiatric problem. 1149 new patients were included from January to November 2009. A study of 207 patients who had a direct care pathway assessment found that the needs assessment process took on average 3 days. 63% patients were directed to a sleep specialist, 16% directly to a behavioural therapy group, 18% to a consulting GP and 3% to another management option. Behavioural therapy groups were proposed to 163 patients, of whom 129 completed at least one session. A study of the 102 patients who completed the entire programme and the evaluations found a significant improvement in the key indicator: the insomnia severity scale (17.3%–14.4% p<0.0001). A study of 55 patients who were followed up at 3 months found that 77% maintained their improvement or continued to improve. Multivariate analysis was performed in order to validate the sleep questionnaire. Principal components analysis identified three factors which explained 58.9% of the variance and were internally coherent. Multiple correspondance analysis found clustering of symptoms and sleep disorders, allowing the construction of a predictive model. The model was able to identify (post-hoc) 88% of sleep apnea patients and 91% o","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":"85200801","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":"179 Multidrug resistant bacteria control at Assistance Publique-Hôpitaux de Paris: a 15 year-experience","authors":"F. Sandra, Brun Christian, Jarlier Vincent","doi":"10.1136/qshc.2010.041616.5","DOIUrl":"https://doi.org/10.1136/qshc.2010.041616.5","url":null,"abstract":"Multidrug resistance (MDR) of bacteria causing healthcare associated infections (HAI) jeopardizes the quality of care by (a) making more difficult the treatment of HAI and (b) increasing the incidence of HAI at least for the case of methicillin resistant Staphylococcus aureus (MRSA). Assistance Publique Hôpitaux de Paris, the largest public healthcare institution in France (38 teaching hospitals scattered over Paris and suburb, 23.000 beds) launched in 1993 a long term program to control and survey MDR. The 1st step was to set up bundle measures to control cross transmission (identification of MDR carriers, barrier precautions) of MRSA and extended-spectrum betalactamase producing enterobacteriacea (ESBL), the incidence of which was higher in France compared to other European countries. The 2nd step was a large campaign launched in 2001–2002 to promote the use of alcohol-based hand rub solution (ABHRS). The 3rd step was to set up in 2004 a specific strategy to control quickly the outbreaks of emerging MDR (vancomycin resistant Enterococcus (VRE), carbapenemase producing enterobacteria (E.carbases)): cohorting cases and contact patients, intervention of the central infection control team (ICT) to assist local ICT for each outbreak. Finally, a large long lasting campaign to decrease antibiotics consumption and, consequently, the selection pressure on MDR was launched in 2006. The above actions implemented by all AP-HP ICT were supported by a strong commitment of AP-HP central and local administration. The main results were as follows: (a) ABHRS consumption increased from 2 to 24 l per 1000 days of hospitalisation (DH), (b) antibiotic consumption decreased by 12% between 2005 and 2008 (528 to 464 defined daily doses/1000DH respectively), (c) the incidence of MRSA, including MRSA bacteraemia, decreased (55% overall in acute care, 70% in intensive care units) and (d) all VRE and E.carbases outbreaks were rapidly brought under control. However, the incidence of ESBL, involving mainly Klebsiella pneumoniae and Escherichia coli, increased markedly since 2002, justifying to adapt our program, particularly concerning antibiotic policy. La multirésistance aux antibiotiques des bactéries (BMR) causant des infections associées aux soins représente un risque pour la qualité des soins car (1) elle rend plus difficile le traitement de ces infections et (2) tend à augmenter l'incidence de ces infections, au moins dans le cas des Staphylococcus aureus résistants à la méticilline (SARM). L'Assistance Publique-Hôpitaux de Paris (38 hôpitaux en Ile de France, 23 000 lits) s'est engagée en 1993 dans un programme de maîtrise et de surveillance des BMR. L'action a d'abord porté sur la prévention de la transmission croisée (identification des porteurs, isolement technique) des SARM et des entérobactéries productrices de bétalactamase à spectre étendu (EBLSE), dont l'incidence était très élevée en France par rapport à d'autres pays européens. C","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":"77823706","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}