Avi Israeli

Containment of a Country-wide Outbreak of Carbapenem-Resistant Klebsiella pneumoniae in Israeli Hospitals via a Nationally Implemented Intervention

BACKGROUND During 2006, Israeli hospitals faced a clonal outbreak of carbapenem-resistant Klebsiella pneumoniae that was not controlled by local measures. A nationwide intervention was launched to contain the outbreak and to introduce a strategy to control future dissemination of antibiotic-resistant bacteria in hospitals. METHODS In March 2007, the Ministry of Health issued guidelines mandating physical separation of hospitalized carriers of carbapenem-resistant Enterobacteriaceae (CRE) and dedicated staffing and appointed a professional task force charged with containment. The task force paid site visits at acute-care hospitals, evaluated infection-control policies and laboratory methods, supervised adherence to the guidelines via daily census reports on carriers and their conditions of isolation, provided daily feedback on performance to hospital directors, and intervened additionally when necessary. The initial intervention period was 1 April 2007-31 May 2008. The primary outcome measure was incidence of clinically diagnosed nosocomial CRE cases. RESULTS By 31 March 2007, 1275 patients were affected in 27 hospitals (175 cases per 1 million population). Prior to the intervention, the monthly incidence of nosocomial CRE was 55.5 cases per 100,000 patient-days. With the intervention, the continuous increase in the incidence of CRE acquisition was halted, and by May 2008, the number of new monthly cases was reduced to 11.7 cases per 100,000 patient-days (P<.001). There was a direct correlation between compliance with isolation guidelines and success in containment of transmission (P=.02). Compliance neutralized the effect of carrier prevalence on new incidence (P=.03). CONCLUSIONS A centrally coordinated intervention succeeded in containing a nationwide CRE outbreak after local measures failed. The intervention demonstrates the importance of strategic planning and national oversight in combating antimicrobial resistance.

The second phase of priority settingGoodbye to the simple solutions: the second phase of priority setting in health careFairness as a problem of love and the heart: a clinician's perspective on priority settingIsrael's basic basket of health services: the importance of being explicitly implicit

What follows is the description of an improved hydraulic apparatus for the automatic adjustment of the inclination of the headlights of a motor vehicle, the adjustment being a dependent function of the axle load. The apparatus has a level sensor at each axle and each level sensor contains one metering piston and two positioning pistons. The rear axle level sensor is connected via two separate hydraulic lines to the front axle sensor, and the front axle sensor is in turn connected via two separate hydraulic lines to the positioning elements of the headlight housings. The internal construction of the two level sensors is substantially identical and is chosen such that the system is also suitable for manual adjustment.

Mortality differentials among women: the Israel Longitudinal Mortality Study.

The first aim of this study was to examine differentials in mortality among Israeli adult women with respect to ethnic origin, marital status, number of children and several measures of socio-economic status; the second was to compare mortality differentials among women with those found for Israeli men. Data are based on a linkage of records from a 20% sample of the 1983 census with the records of deaths occurring until the end of 1992. The study population includes 79,623 women and the number of deaths was 14,332. Measures of SES included education, number of rooms, household amenities and possession of a car. Results indicated higher mortality among women originating from North Africa compared with Asian and European women. Adjustment to SES eliminated the excess mortality among North African women and revealed a lower mortality of Asian women, relative to Europeans. Among women aged 45-69, substantial and consistent mortality differentials were evident for all SES indicators examined where mortality declined with improved socio-economic position. Mortality was related to womens childbearing history, with the highest mortality among childless women. Mortality differentials among women aged 70+ were generally narrower than those found for younger women. Gender differences in mortality differentials varied by the socio-demographic indicator and age.

MODELS OF GERIATRICS PRACTICE: Decreased Hospital Utilization By Older Adults Attributable to a Home Hospitalization Program

OBJECTIVE: To evaluate the cost effectiveness of a short‐term home health care program for older people, Home Hospitalization (HH), compared with the alternative of regular ambulatory care with general or geriatric hospitalization as necessary.

Measles in a highly vaccinated society: the 2007-08 outbreak in Israel.

BACKGROUND Despite success in controlling measles through a national immunization program, Israel recently experienced its largest measles outbreak since 1994. METHODS Using data reported by health district offices to the Ministry of Health, an epidemiological analysis of the 2007-08 measles outbreak was performed. RESULTS 1467 measles cases were reported in Israel, primarily among ultra-orthodox Jewish communities in the Jerusalem Health District and to a lesser extent in other areas. The highest age-specific incidence rate (122.5 per 100,000) occurred among infants. 38.6% of all measles patients were under the age of five, and 53.4% were under the age of ten. 186 patients (12.7%) were hospitalized; there were no fatalities. Only 4.6% of measles patients had been fully vaccinated for their age. CONCLUSION To minimize the risk of future outbreaks in Israel, successful marketing of the MMR vaccine to under-vaccinated sub-groups is essential.

Health and health care in Israel: an introduction

Starting well before Independence in 1948, and over the ensuing six decades, Israel has built a robust, relatively efficient public system of health care, resulting in good health statistics throughout the life course. Because of the initiative of people living under the British Mandate for Palestine (1922-48), the development of many of todays health services predated the states establishment by several decades. An extensive array of high-quality services and technologies is available to all residents, largely free at point of service, via the promulgation of the 1994 National Health Insurance Law. In addition to a strong medical academic culture, well equipped (albeit crowded) hospitals, and a robust primary-care infrastructure, the country has also developed some model national projects such as a programme for community quality indicators, an annual update of the national basket of services, and a strong system of research and education. Challenges include increasing privatisation of what was once largely a public system, and the underfunding in various sectors resulting in, among other challenges, relatively few acute hospital beds. Despite substantial organisational and financial investment, disparities persist based on ethnic origin or religion, other socioeconomic factors, and, regardless of the countrys small size, a geographic maldistribution of resources. The Ministry of Health continues to be involved in the ownership and administration of many general hospitals and the direct payment for some health services (eg, geriatric institutional care), activities that distract it from its main task of planning for and supervising the whole health structure. Although the health-care system itself is very well integrated in relation to the countrys two main ethnic groups (Israeli Arabs and Israeli Jews), we think that health in its widest sense might help provide a bridge to peace and reconciliation between the country and its neighbours.

Launching the Israel Journal of Health Policy Research: Why a new journal? Why now? Why open access?

The Israel Journal of Health Policy Research (IJHPR) is a new, open access journal. IJHPR seeks to promote intensive intellectual interactions among scholars and practitioners from Israel and other countries regarding all aspects of health policy, with particular attention to Israel. The ultimate aim of these interactions is to contribute to the development of health policy in Israel, and also to foster wider communication between health scientists and policy analysts in Israel and their colleagues around the world. This inaugural editorial provides an overview of the new journals rationale and its key features.

Load index model: An advanced tool to support decision making during mass-casualty incidents.

BACKGROUND In mass-casualty events, accessing information concerning hospital congestion levels is crucial to improving patient distribution and optimizing care. The study aimed to develop a decision support tool for distributing casualties to hospitals in an emergency scenario involving multiple casualties. METHODS A comprehensive literature review and structured interviews with 20 content experts produced a shortlist of relevant criteria for inclusion in the model. A “load index model” was prepared, incorporating results of a modified Delphi survey of 100 emergency response experts. The model was tested in three simulation exercises in which an emergency scenario was presented to six groups of senior emergency managers. Information was provided regarding capacities of 11 simulated admitting hospitals in the region, and evacuation destinations were requested for 600 simulated casualties. Of the three simulation rounds, two were performed without the model and one after its presentation. Following simulation experiments and implementation during a real-life security threat, the efficacy of the model was assessed. RESULTS Variability between experts concerning casualties’ evacuation destinations decreased significantly following the model’s introduction. Most responders (92%) supported the need for standardized data, and 85% found that the model improved policy setting regarding casualty evacuation in an emergency situation. These findings were reaffirmed in a real-life emergency scenario. CONCLUSION The proposed model improved capacity to ensure evacuation of patients to less congested medical facilities in emergency situations, thereby enhancing lifesaving medical services. The model supported decision-making processes in both simulation exercises and an actual emergency situation.

Interventions for reducing readmissions - are we barking up the right tree?

Readmission reduction is at the focus of health care systems worldwide in efforts to improve efficiency across care settings. Yet, setting targets for readmission reduction is complicated due to inconsistencies in evidence pointing to effective organization-wide interventions and because of inverse incentives (such as maintaining high occupancy rates). Nonetheless, readmission reduction is one of the few quality measures that, if implemented properly, can serve as a catalyst for system integration. Appropriate mechanisms should be applied to hospitals as well as ambulatory settings to ensure that accountability is assigned to all stakeholders.

Decision to evacuate a hospital during an emergency: The safe way or the leader's way?

Hospitals have frequently been evacuated because of natural or man-made disasters. In this article, we identify elements to be considered when confronted with the possibility of hospital evacuation. Hospital evacuation may have a significant impact on the surrounding community and the overall population. When the patients in a hospital are placed at risk, hospital leadership often decides to evacuate the facility to safeguard the well-being of both patients and staff. Such a decision is not likely to be criticized. We present various considerations. The effect of evacuation on patients, hospital staff, family members, the community, and even the nation as a whole, as well as repercussions affecting potential patients should be integral to the decision-making process and parallel to the risk assessment.