Quality and Safety in Health Care最新文献

{"title":"039 Clinical pathway for pain management in a pain day care unit: use of intravenous lidocaine for neuropathic pain","authors":"Piano Virginie, Rabary Olivier, L. Michel","doi":"10.1136/QSHC.2010.041624.91","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.91","url":null,"abstract":"Background and objectives In pain management clinics, refractory chronic pain often needs to be managed by potentially iatrogenic treatments that have not been fully validated in terms of evidence-based medicine, such as intravenous lidocaïne treatment for neuropathic pain (NP). Our primary objective was to evaluate professional practices in the pain day care unit of Nice university hospital. Secondary objectives were to study the efficacy and safety of intravenous lidocaine treatment of NP and to assess the heath economics impact of our quality improvement programme. Programme Our quality improvement programme was part of a wider initiative to harmonise clinical practices in pain clinics in France. It took place between November 2007 and September 2009 and was implemented by three physicians. It followed the Plan-Do-Check-Act procedure. ‘Plan’: The first step was (i) a systematic literature review on the use of intravenous lidocaine to treat NP, (ii) consultation of the HAS practice appraisal process and of the 2010 version of the HAS accreditation manual for healthcare organisations, and (iii) consultation of the rules and regulations on day hospitals. After an analysis of quality improvement methods used in day hospitals, we selected the clinical pathway method. ‘Do’. A multidisciplinary team meeting (MTM) on pain was held every week in order to validate the indications for intravenous lidocaine and monitor progress. The following documents were drawn up: a care protocol, procedures to be followed in the case of adverse events, a patient information and consent form, a prescription and evaluation form, a standard letter requesting an evaluation by a cardiologist, MTM and hospital reports for the GP, a phone follow-up form. A vital signs monitor was purchased and emergency trolley equipment was brought up to standard. ‘Check and act’. Three audit rounds were carried out using a 10-item questionnaire. Data on efficacy (pain intensity on a visual analogue scale (VAS), patient satisfaction), safety (‘active’ recording of side effects), and health economics were collected. Results The quality improvement programme was integrated by the pain team into their daily practice. Between the first and last round of the audit, compliance with quality criteria increased markedly from 45%–95% to 80%–100%, according to item. Overall, 53% (63/119) of patients experienced a 30% reduction in pain intensity (VAS) and 29.4% (35/119) reported that they were satisfied or very satisfied with the treatment. Adverse events occurred in 46% of patients (55/119). There were four early treatment interruptions but no serious adverse events. After an initial 36% reduction in 2008, the recruitment level at the end of the programme was identical to that before programme implementation. A clear increase in activity-based funding was observed at the end of the programme (+66%). Discussion Our programme led to an improvement in practice. This justified the resources allocated wit","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":"87429696","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":"284 Implementation of a multidimensional program to improve medical prescription in the elderly within a university hospital nephrology unit","authors":"C Tourette-Turgis, C. Bagnis, M. Rébillon, L. Pereira-Paulo","doi":"10.1136/QSHC.2010.041632.40","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041632.40","url":null,"abstract":"Objectives and Context Chronic kidney disease (CKD) patients over 65 mostly suffer from two or more comorbidities (75% have hypertension, 35% have diabetes) with a mean of 4.5 chronic conditions. Prescriptions delivered by the Nephrology unit of a University Hospital in a urban area show an average number of medications from 6 to 15 different drugs for the treatment of both acute events and several chronic diseases. Patients seem to hierarchise their intake of medications according to the negative impact of symptoms on their quality of life, (such as pain, discomfort) and tend to omit taking medications that are active on silent symptoms although these symptoms if not addressed may be life threatening. Moreover, the design of most drugs (pills, or inaccurately labelled containers, leaflets) is not appropriate for the elderly especially for those suffering from disabling comorbidities (sight defect, cognitive disorder or troubles with fine grasping in the case of arthritis). The burden of the number of medication prescribed and the complexity of changes expected from the patients to appropriately cope with the prescribed regimen is particularly heavy to elderly patients. In other words, CKD seniors cannot develop their own self-care skills and therefore experience frequent unintentional adherence or relapse/complications in their care caused by external conditions. These obstacles have a serious negative impact on their health maintenance and outcomes. Therefore, educational programs for the elderly with CKD must focus on strategies to avoid or prevent non intentional non adherence. Methods A multidisciplinary integrated educational program was implemented in 2007 in the Nephrology department with: analysis of patients' needs through a survey (interviews of 21 patients) analysis of the subjective experience of dialysis sessions in 14 patients and 15 nurses working in the dialysis unit design of a survey exploring patients' educational needs outpatient consultation delivered by trained nurses on adherence available 6 days a month weekly educational and patient workshop including the results of the survey focused on patients' needs creation of educational material on more than 20 different medications (information leaflet for patients) «medication info» consultation for every patient checking out from the nephrology unit intensive communication and training program on «education in chronic disease) towards health care providers in the renal unit design of educational tools for the team performing educational sessions: poster with life-size pictures of pills for 61 of the most frequently prescribed drugs, therapeutic planning, risk reduction pyramid for drug's use, scripts for interviewing patients (to work on adherence)… Results Improvement of care coordination Use of a negotiated prescription process» after having worked individually together with the patient on the aims of the therapeutic projects and having defined common goals for the patient an","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":"85387665","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":"072 Clinical impact of quality improvement actions decided in morbidity-mortality reviews (MMR) in intensive care units","authors":"C. Philippe, Moret Leila, Naux Edouard, Vanier Antoine, Demeure Dit Latte Dominique, Asehnoune Karim","doi":"10.1136/qshc.2010.041616.3","DOIUrl":"https://doi.org/10.1136/qshc.2010.041616.3","url":null,"abstract":"Background and objectives The development of morbidity-mortality reviews (MMR) in high-risk units is one of the main objectives of the quality improvement policy of Nantes university hospital. Currently, 25 units are engaged in the analysis of clinical adverse events. Our surgical intensive care unit (ICU) was a forerunner in implementing this policy. Programme The ICU has 14 beds and an average intake of 700 patients per year. MMRs have been taking place every 2 months since January 2007. MMR participants are the medical staff of the unit, any on duty physicians, nursing staff and other allied healthcare professionals, and external experts whenever required. A charter establishing rules has been drawn up. The following adverse events are collected in a restricted access database: deaths, unplanned extubations, events related to medical devices, falls, near-misses, unplanned readmissions, and problems with handover communication. The person responsible for the database reviews all data entered and selects the files requiring in-depth analysis (2 to 5 files per meeting). A report with suggested improvement actions is handed to all concerned at the end of the meeting. A process indicator for each type of adverse event is applied once a year to measure the impact of the actions undertaken. Results and clinical impact From January 2007 to December 2008, 1411 patients were hospitalised in our ICU (693 in 2007, 718 in 2008). A total of 199 adverse events were entered into the database, 70 files were reviewed (MMR), and 25 improvement actions were undertaken. A statistically significant impact was observed for 3 types of improvement action: (i) increasing staff awareness of agitation in patients, (ii) updating protocols for sedation and physical restraint, (iii) purchasing better suited medical supplies. We noted a 46% decrease in the number of unplanned extubations (they fell from 20 (0.59/100 days of ventilation) to 11 (0.32/100 days of ventilation), p<0.01), a 85% decrease in the number of snatched medical devices (from 20 to 3, p<0.001), and the disappearance of accidental falls from the bed or chair (from 3 to 0). Such events are common in surgical ICUs which frequently admit patients with head trauma or patients intoxicated by alcohol or drugs. Discussion and conclusion A quality improvement programme that has a positive clinical impact promotes staff motivation. Interest in measuring the quality of health care is increasing among health care professionals. We are now including further variables in our database in order to optimise nurse planning (eg, patient-to-nurse ratio, where the nurse was when the adverse event occurred). Further developments should include promoting nursing staff participation through education and the choice of a time slot for the meetings compatible with high attendance. High attendance can help alleviate fears of judgemental attitudes. MMRs have also encouraged staff interest in patient safety. Sharing results among team","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":"86688728","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":"102 Antibiotic Kit for antibioprophylaxis in surgery: promoting the best use of antibiotics in the operating room","authors":"Carles Michel, Bornard Loic, L. Florence, Raucoules Marc","doi":"10.1136/QSHC.2010.041624.35","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.35","url":null,"abstract":"Setting Surgical antibiotic prophylaxis is one of the critical tools to prevent Surgical Site Infections (SSIs) and needs, for its optimisation, to be in accordance with specific guidelines. Antibiotic consumption in the operating room reaches almost 30% of the total hospital antibiotic expenses and thus is a major goal in the way to improve the overall antibiotic use. The implementation of personalised surgical antibiotic prophylaxis kits (SAPKs) has been associated with an improvement of the compliance to the guidelines (82% of consistency).1 Nevertheless, these kits are associated with a additional work load impairing their use in daily practice. The aim of the process presented here is to move from personalised to SAPKs « by type of surgery » in the way to make the implementation of SAPKs easier and sustainable without impairing its efficiency. Program Kits are made at the Hospital Pharmacy (in accordance with the French Society of Anesthesiology (SFAR) Guidelines. They are individual small paper bags including the labelling of the kit and the antibiotic (name and dose, how to use it). The allocation of the all week antibiotics is renewed every Friday by the Hospital Pharmacy (full-empty replacement using a rolling closet located in the recovery room). To assess the impact of this process we designed an exposed-non exposed prospective study (Visceral and Orthopaedic Surgeries) defining two groups: non exposed patients having a freely prescribed surgical antibiotic prophylaxis (fpSAPKs) versus « by type of surgery » (tsSAPKs). Results 420 patients have been included. The two groups are comparable regarding the type of surgery (Orthopaedic 33%, Visceral 66%), the age, gender, ASA and Altemeier classes and duration of surgery. A surgical antibiotic prophylaxis has been prescribed in 88% of cases in the fpSAPKs versus 90% in tsSAPKs (p=ns). The assessment of the main points of antibiotic prophylaxis use showed a significant improvement of the consistency of the reason of the prescription (93% vs 86%, p=0.01) and of the chosen drug (88% vs 81%, p=0.04). The only one criteria not improved was the delay between the time of antibiotic infusion and the beginning of surgery (organisational constraints). The routine use of antibiotic kits allowed to remove any antibiotic storage in the operating room and to improve the medical prescription's follow up through a computerised information system. With the kits, the number of different antibiotics used in the operating room decreases from 28 to 8. The complete accordance to the guidelines increases from 75% to 87% in the tsSAPKs group (p<0.01). Discussion The implementation of SAPKs « by type of surgery » allowed to improve the level of conformity to the guidelines. This sustainable process (since 2005) ensures the mandatory (legal issue) follow up of the prescriptions of antibiotics. Contexte L'antibioprophylaxie (ABP) est un des moyens essentiels de prévention des infections du site opératoire. La conso","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":"90458256","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":"144 Improvement by the evaluation of professional practices of decision making of relative to the limitation or discontinuance of treatment (LATA)","authors":"Larché Jérôme, B. Masson, Pierre Cocquet, M. Piqué, Ginot Jean, J-Claude Gouiry","doi":"10.1136/QSHC.2010.041624.26","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.26","url":null,"abstract":"Literature shows that the decisions to limit or stop the therapeutic treatment of patients (LATA) concerns, in intensive care unit (ICU), 10% of adult patients admitted and over 50% of patients who died. The law of the 22nd of April 2005 (Law Leonetti) recognises the necessity to prevent the use of intensive medication (meaning an inadequate use of “prolonged artificial life support”), sharing of sensitive medical information with families and favours the intra-hospital ethical reflexion. An evaluation of professional practises (EPP) designed to improve the methods of decision-taking for LATA among Narbonne Hospital's ICU was implemented between June 2008 and November 2009. Founded on the principles of the Law Leonetti, an evaluation form on the practises of LATA was drafted in June 2008, containing five items: The advice of the medical and Para medical team is recorded and noted in the medical file. The advice of the consultant doctor is taken into consideration. The advice of proxy (family and friends) is taken into consideration. A record of evidence on decisions taken (traceability). The name and function of people who participated in the decision is written in the medical file. This form allowed primarily a retrospective analyse of patient's files that were part of limited or withdrawal of medical intervention (LATA) in 2007. This audit was followed in October 2008, within ICU, by a promotion and propagation of the principles of the Law Leonetti and the protocol to follow, for LATA decision-taking. A prospective audit was then taken from November 2008 to November 2009 to assess the impact and efficiency of these improvement actions on LATA decision-taking process. The principle results of this retrospective audit (n=26 patients) established that 58% of the files did not contain the advice of the medical team, 73% of files did not contain the advice of consulting doctor, 50% of cases did not contain the advice of close proxy and only 54% of the medical files showed some traceability of the decisions taken. And not one medical file showed the name of persons who took the decisions for LATA. After these results, distributed throughout the Narbonne Hospital's ICU, an information has been widespread to the staff in October 2008, on Law Leonetti and on the protocol foreseen for LATA decision-taking. From November 2008 until November 2009 a prospective audit was performed in ICU on LATA's policy decisions. Out of 27 medical files examined, traceability of the medical team and the advice of consulting doctors weres found in 96.3% (26 out 27 files), traceability of all other items was 100% of the medical files. The results of this EPP can be considered positive, with an improved medical management in delicate and sensitive medical conditions. They also favour a collective acceptance—by medical and paramedical staff involved in ICU—of these frequent decisions and their impact, and their heavy consequences for patients and their families. We also consi","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":"89635586","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":"183 Program for the improvement of pain management in the CHU of Bordeaux. Impact on pain prevalance, patient satisfaction and the traceability of pain","authors":"N. Robinson, F. Stark","doi":"10.1136/QSHC.2010.041616.21","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041616.21","url":null,"abstract":"Introduction—Objectives Bordeaux University Hospital has conducted a total quality improvement program about pain management. After several surveys it selected five quality indicators about pain management and organised the continuous collection of them by professionals. The indicators are patient satisfaction on pain management, patient information on pain management, pain traceability, pain prevalence and pain treatment existence. The objectives of this program and follow-up of a set of five indicators were to improve pain management in all the departments of Bordeaux University Hospital. Program The three steps of the program are the following: (1) diffusion of guidelines on pain management, (2) intranet framework constitution for indicators collection, and (3) project follow-up. Results The table shows the results of the indicators between 2006 and 2009 Table 2006 2007 2008 2009 Adults 1718 1972 1851 2250 Traceability (%) 53.4 59.9 61.9 60.3 Pain treatment (%) 57.5 59.9 61.9 60.3 Pain prevalence (%) 27.6 26.9 29.7 23.8 Pediatrics 219 194 170 315 Traceability (%) 45.2 72.2 67.7 51.7 Pain treatment (%) 50.7 45.9 49.4 47.8 Pain Prevalence (%) 31.3 21.4 8.6 18.4 The results show a lowering of pain prevalence, particularly in pediatrics and the improvement of pain traçability. Discussion Indicators are collected in routine. They allow comparisons about pain management quality. These indicators are simple, quick and reproductible. They allow to address priority about pain management action and the follow-up of these actions on quality of pain management. Introduction—objectifs Malgré les progrès de ces dernières années, la douleur reste un symptôme présent chez environ 1 patient sur 3 hospitalisé au CHU de Bordeaux. Le CLUD (comité de lutte contre la douleur) du CHU de Bordeaux dès sa mise en place (1998) a mené une enquête unique en France, établissant l'état des lieux de la prise en charge de la douleur (1999). Les objectifs étaient de décrire les modalités d'information, de diagnostic, de traitement et de suivi des patients douloureux et de décrire les résultats de cette prise en charge pour les patients douloureux. Cette enquête a été ensuite été étendue à 13 établissements de l'Aquitaine membre du CCECQA en 2000. Suite à cette première enquête, le CLUD s'est inscrit dans une démarche de recherche continue d'amélioration de la prise en charge de la douleur. En novembre 2003, une nouvelle enquête reposant sur la même méthodologie a été menée, dans le cadre des Etats Généraux de la douleur. Le CHU fait partie des établissements participants au projet COMPAQH. De plus, le CLUD travaille en commission dont l'une a pour thème l'évaluation par indicateurs de la Prise en charge (PEC) de la douleur. En partenariat avec le CCECQA 5 indicateurs ont été retenus pour le suivi de la PEC de la douleur: Satisfaction des patients vis-à-vis de la prise en charge de la douleur Information des patients sur la prise en","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":"91455349","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":"032 Risk cartography and professional practice in the management of severe sepsis and septic shock in Intensive Care Unit","authors":"A. Barbe, Olivier Pichenot, V. Kostusiak, M. Philippe","doi":"10.1136/qshc.2010.041624.24","DOIUrl":"https://doi.org/10.1136/qshc.2010.041624.24","url":null,"abstract":"Objectives In Intensive Care Unit (ICU), the epidemiological data show a high incidence of severe sepsis syndromes associated with a significant mortality rate. The quality and safety of care must be insured by a fast and adapted management. To ensure septic patients safety, an evaluation of the professional practices (EPP) coupled with a cartography of risks was conducted in the ICU of the French Hospital of Charleville-Mézières. The attempted objectives were to perform an inventory of the practices by taking into account the therapeutic aspects and the timing of care, and by analysing risks, in order to offer a plan for improvement of practices. Program During a 5 months period, a clinical audit and a clinical pathway were realised on 17 patients presenting a severe sepsis or a sepsis shock. The clinical audit included clinical data, haemodynamic, biological and antibiotic management modalities. To optimise the evaluation of this support, the clinical pathway included the EPP criteria at the 1st, the 6th, and the 24 h after diagnosis. The preliminary analysis of risks (PAR) allowed to define a cartography of dangerous situations (DS) according to gravity of the consequences (delay of care, impact on the organisation of the care, loss of chance, adverse effects) and to their likelihood (percentage of the patients presenting a severe sepsis). The hierarchical organisation of risks was realised according to three levels of approval of the risk (C1: acceptable, C2: admissible, C3: unacceptable). Results The results show an incidence of sepsis and sepsis shock of 10%, and a mortality rate of 35% among this population. In the clinical audit, four criteria were not fulfilled (conformity rate <60%) for example “antibiotic treatment” showing a critical threshold of 35%. The analysis of the clinical pathway reveals that none of the criteria was present for the 60% threshold with a critical threshold <35% for the SvO2 criteria and < 6% for the titration of fluid therapy. The PAR highlights the critical stage of care management (1 h: 40% of DS, and between 1 and 6 h: 38%) as well as the dangerous elements (clinical practices and technological equipments: 50% DS). The cartography of initial risks shows the following distribution of the DS: C1: 9%, C2: 38%, C3: 53%. The improvement plan contains 47 actions concerning organization, actors knowledge, investment, and quality indicators. The impact of the plan is measured by determining the residual criticality of identified scenarios stemming from the residual gravity of the consequences and their likelihood after establishment of the actions. This action plan allows removing unacceptable DS and considerably increases the number of acceptable situations from 9 to 60% (C1: 60%, C2: 40%, C3: 0%). Discussion The level of safety practice defined by the disappearance of the C3 risks, is applicable only if the actors know and apply actions of improvement. The motivation and the accompaniment of the professionals 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":"77394408","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":"289 Improving safety of patient treated by vitamin K antagonists in geriatrics","authors":"C. Bussy, P. Ghiassi, C. Oasi, S. Pariel, S. Chauvelier, M. Sohane, J. Belmin","doi":"10.1136/QSHC.2010.041624.73","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041624.73","url":null,"abstract":"Background Vitamin K antagonists (VKA) are widely used in old patients with atrial fibrillation or venous thromboembolism. Safety is a major concern, especially in old patients. International normalised ratio (INR)>5 is associated with an increased risk of bleeding and is considered as a near miss error. Aim To reduce the incidence of episodes of INR>5 which occurred during the hospital stay of patients of a geriatric hospital ward exposed to VKA. Design: Intervention study, non randomised. Methods The study was done in five geriatric wards comprising acute, intermediate and long-term care beds of a French hospital. The intervention was conducted in one ward of the hospital. A structured teamwork among the medical staff of the geriatric ward was implemented from July to December, 2005. Twice monthly, the medical staff examined during a short meeting the cases of all the patients with INR>5 which occurred during the preceding weeks. The group discussed cases using a tool designed to identify prescribing errors in dose adjustment and/or INR monitoring. The approach was proactive in order to learn from errors and not punitive. The number of patients exposed to VKA and the number of episodes of INR>5 were recorded during a 12-month period before the intervention (2004–2005) and during the year following it in the intervention ward and in control wards (2006). Results In control wards, 60 episodes of INR>5 were recorded in the 267 patients (22.5%) receiving VKA in 2004–2005 and 56 episodes among the 263 (22.1%) in 2006. In the intervention ward, 22 episodes were recorded in the 72 patients (30.6%) in 2004-2005, and 16 episodes of INR>5 were recorded among the 92 patients (17.4%), corresponding to a significant decrease (−43.1%) as compared to control wards (–1.8%, p<10–4). Conclusion A structured teamwork focused on cases of INR>5 lessen the risk of VKA overdosage and might improve safety of anticoagulation. Learning from errors seems an efficient way to improve quality of care. Contexte Les antivitamines K (AVK) sont largement utilisées chez les patients âgés ayant une fibrillation auriculaire ou une maladie veineuse thromboembolique. La sécurité est une préoccupation majeure, en particulier chez les patients âgés. L'international normalised ratio (INR)>5 est associé à une majoration du risque de saignement et est considéré comme un événement critique. But Réduire l'incidence des épisodes d'INR>5 survenant pendant le séjour hospitalier chez les patient d'un service de gériatrie recevant des AVK. Type d'étude Interventionnelle non randomisée. Méthodes L'étude a été conduite dans 5 services hospitaliers de gériatrie comprenant des lits de court séjour, de soins de suite-réadaptation et soins de longue durée. L'intervention a été conduite dans un service de l'hôpital. Un travail structuré au sein de l'équipe médicale a été conduit de juillet à décembre 2005. Deux fois par mois, l'équipe médicale a examiné durant ","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":"80935597","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":"163 Management of shoulder pane in hemiplegic patients in a multidisciplinary team","authors":"T. Myriam, R. Olivier, Kermarrec Solange","doi":"10.1136/qshc.2010.041624.53","DOIUrl":"https://doi.org/10.1136/qshc.2010.041624.53","url":null,"abstract":"The management of pain is a public health issue. It's a part of the institutional project of care of the University Hospital of Brest. Shoulder pain affects 15 to 70% of hemiplegic patients after stroke admitted to Physical and Rehabilitation Medicine (PRM) units. It has a negative impact on the PRM programs and on the functional results after upper limb rehabilitation. In the absence of consensus treatment, prevention outweighs support. Hemiplegic stroke patients represent 70% of recruitment of the PRM neurological unit. A program of quality enhancement of clinical practice was conducted (using the resolution of problems) in 2006. The objective was the assessment of the incidence and the improvement of the management of shoulder pain. Malfunctions in all stages of care have been identified (prevention, information, diagnosis, treatment…) and led to define different actions for improvement: Preventive measures: staff training (the training program was held in 2007), education of patients and their relatives (practical training of upper limb mobilisation, positioning, transfers, writing of a booklet of education), purchasing equipment after identification, training healthcare teams upstream services (training provided in 2007 and early 2008) and information of external speakers (disseminate the brochure of education) Assessment or risk factors: screening of the pain and risk factors at enrolment (target entry sheet for nurses), regular assessment group summary Traceability or the treatment: monitoring therapeutic actions in a computerised medical record network Coordination of care: development of a protocol ‘prevention and management of shoulder pain of hemiplegic patients’ Monitoring indicators have been defined: Care records (entry sheet for nurses, opening the specific computer file after diagnosis, initiation of a target in targeted transmission of care) Assessment of staff knowledge (knowledge level before and after training) Changing the number of patients suffering from hemiplegic shoulder pain before, during, 1 and 3 years after the program. With a number of hemiplegic relatively stable over 4 years (between 93 and 101 per year), results show: In 2005 and 2006 (before and during the process), respectively 13% and 14% of patients had shoulder pain, 66 and 57% were acquired during their stay. In 2007 a 57% reduction in the number of shoulder pain was observed (ie 8% of the total number of hemiplegic patients hospitalised in the unit) of which 26% were acquired during their stay. In 2009, 14% of patients had shoulder pain and 50% were acquired during their stay. Initially, apart from improved knowledge in particular on the importance of prevention, care coordination and formalisation of practice, this program of quality improvement has significantly reduced the number of patients suffering from shoulder pain during their stay in the PRM unit. Early detection, recorded comprehensively, enables besides an immediate management of the patient 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":"80109651","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":"108 A public health intervention program to improve the initial management of soft tissue sarcomas","authors":"C. Bellera, B. Bui, C. Chevreau, É. Bauvin, F. Pelissier, P. Grosclaude, M. Savès, E. Bompas, S. Albert, S. Mathoulin-Pélissier","doi":"10.1136/QSHC.2010.041608.6","DOIUrl":"https://doi.org/10.1136/QSHC.2010.041608.6","url":null,"abstract":"Context Soft tissue sarcomas (STS) are rare tumours. In France, STS is estimated to represent about 1% of all cancers, the true incidence of which remains unknown. Management of STS is particularly difficult due to the initial diagnosis which is complex (more than 50 histological subtypes). Moreover, initial surgery is often inappropriate as surgery is usually performed before biopsy resulting in complex decisions once STS is histological proven. Objectives A quasi-experimental before/after study (with control region) was implemented to set up and evaluate a public health intervention aimed at improving the quality of the initial management of STS (diagnosis and surgery). Additional objectives involved measuring the impact of this intervention, exploring factors associated in variations in the quality of STS management, and estimating STS incidence rate. Program The program was implemented in collaboration with the French Sarcoma Group (FSG), regional cancer registries and cancer regional networks. It involves five regions (covering 20% of the French population). This study was initiated in November 2006 and involves three phases. In the first phase (November 2006 to December 2007), information on STS cases diagnosed during this period was collected. Between January 2008 and October 2008, the public health program was implemented in four regions (the fifth region serves as a control), and involved two distinct actions: (1) written information campaign directed towards all relevant practitioners, and (2) oral communications in dedicated meetings by opinion leaders. Finally, information on STS cases diagnosed after this ‘action’ period was collected. Based on available incidence data, we anticipated that 300 STS cases per year would be recruited. As we were interested in evaluating the quality of STS management before and after the program, a preliminary step involved validating quality indicators (QIs) for cancer care. As such, we assessed which QIs were the most relevant to evaluate the quality of the management of STS. To validate QIs, a Delphi consensus method was set up. Based on Good Clinical Practices and a literature review, we prepared a set of 25 QIs, and relied on a panel of advisory FSG experts (n=19) from multiple medical specialities. We chose to measure the main impact of both actions (diagnosis + surgery) using a composite criterion focussing on three steps of initial management (imaging diagnosis, surgery, and multidisciplinary meeting), since these are directly associated with survival. Results in Terms of Clinical Impact Regarding QIs, consensus was reached for 23 items, with perfect consensus for 9 QIs (eg, the need for multidisciplinary management teams, appropriate surgical biopsy techniques). During the actions phase in the four concerned regions (one region was the control) about 16 000 written information (in the form of one double-sided page) were sent to practitioners; 18 meetings allowed us to increase awareness of about","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":"76723708","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}