Cécile Payet

Patient Mortality Is Associated With Staff Resources and Workload in the ICU: A Multicenter Observational Study.

Objective:Matching healthcare staff resources to patient needs in the ICU is a key factor for quality of care. We aimed to assess the impact of the staffing-to-patient ratio and workload on ICU mortality. Design:We performed a multicenter longitudinal study using routinely collected hospital data. Setting:Information pertaining to every patient in eight ICUs from four university hospitals from January to December 2013 was analyzed. Patients:A total of 5,718 inpatient stays were included. Interventions:None. Measurements and Main Results:We used a shift-by-shift varying measure of the patient-to-caregiver ratio in combination with workload to establish their relationships with ICU mortality over time, excluding patients with decision to forego life-sustaining therapy. Using a multilevel Poisson regression, we quantified ICU mortality-relative risk, adjusted for patient turnover, severity, and staffing levels. The risk of death was increased by 3.5 (95% CI, 1.3–9.1) when the patient-to-nurse ratio was greater than 2.5, and it was increased by 2.0 (95% CI, 1.3–3.2) when the patient-to-physician ratio exceeded 14. The highest ratios occurred more frequently during the weekend for nurse staffing and during the night for physicians (p < 0.001). High patient turnover (adjusted relative risk, 5.6 [2.0–15.0]) and the volume of life-sustaining procedures performed by staff (adjusted relative risk, 5.9 [4.3–7.9]) were also associated with increased mortality. Conclusions:This study proposes evidence-based thresholds for patient-to-caregiver ratios, above which patient safety may be endangered in the ICU. Real-time monitoring of staffing levels and workload is feasible for adjusting caregivers’ resources to patients’ needs.

Combining High-Resolution Contact Data with Virological Data to Investigate Influenza Transmission in a Tertiary Care Hospital

OBJECTIVE Contact patterns and microbiological data contribute to a detailed understanding of infectious disease transmission. We explored the automated collection of high-resolution contact data by wearable sensors combined with virological data to investigate influenza transmission among patients and healthcare workers in a geriatric unit. DESIGN Proof-of-concept observational study. Detailed information on contact patterns were collected by wearable sensors over 12 days. Systematic nasopharyngeal swabs were taken, analyzed for influenza A and B viruses by real-time polymerase chain reaction, and cultured for phylogenetic analysis. SETTING An acute-care geriatric unit in a tertiary care hospital. PARTICIPANTS Patients, nurses, and medical doctors. RESULTS A total of 18,765 contacts were recorded among 37 patients, 32 nurses, and 15 medical doctors. Most contacts occurred between nurses or between a nurse and a patient. Fifteen individuals had influenza A (H3N2). Among these, 11 study participants were positive at the beginning of the study or at admission, and 3 patients and 1 nurse acquired laboratory-confirmed influenza during the study. Infectious medical doctors and nurses were identified as potential sources of hospital-acquired influenza (HA-Flu) for patients, and infectious patients were identified as likely sources for nurses. Only 1 potential transmission between nurses was observed. CONCLUSIONS Combining high-resolution contact data and virological data allowed us to identify a potential transmission route in each possible case of HA-Flu. This promising method should be applied for longer periods in larger populations, with more complete use of phylogenetic analyses, for a better understanding of influenza transmission dynamics in a hospital setting.

Can we consider immediate complications after thyroidectomy as a quality metric of operation

Background. Permanent recurrent laryngeal nerve palsy and hypoparathyroidism are 2 major complications after thyroid operation. Assuming that the rate of immediate complications can predict the permanent complication rate, some authors consider these complications as a valid metric for assessing the performance of individual surgeons. This study aimed to determine the correlation between rates of immediate and permanent complications after thyroidectomy at the surgeon level. Methods. We conducted a prospective, cross‐sectional study in 5 academic hospitals between April 2008 and December 2009. The correlation between the rates of immediate and permanent complications for each of the 22 participating surgeons was calculated using the Pearson correlation test (r). Results. The study period included 3,605 patients. There was a fairly good correlation between rates of immediate and permanent recurrent laryngeal nerve palsy (r = 0.70, P = .004), but no correlation was found for immediate and permanent hypoparathyroidism (r = 0.18, P = .427). Conclusion. The immediate hypoparathyroidism rate does not reflect the permanent hypoparathyroidism rate. Consequently, immediate hypoparathyroidism should not be used to assess the quality of thyroidectomy or to monitor the performance of surgeons.

Determinants of operative time in thyroid surgery: A prospective multicenter study of 3454 thyroidectomies

Objective To identify the determinants of operative time for thyroidectomy and quantify the relative influence of preoperative and intra-operative factors. Background Anticipation of operative time is key to avoid both waste of hospital resources and dissatisfaction of the surgical staff. Having an accurate and anticipated planning would allow a rationalized operating room use and may improve patient flow and staffing level. Methods We conducted a prospective, cross-sectional study between April 2008 and December 2009. The operative time of 3454 patients who underwent thyroidectomy performed by 28 surgeons in five academic hospitals was monitored. We used multilevel linear regression to model determinants of operative time while accounting for the interplay of characteristics specific to surgeons, patients, and surgical procedures. The relative impact of each variable on operative time was estimated. Results Overall, 86% (99% CI 83 to 89) of operative time variation was related to preoperative variables. Surgeon characteristics accounted for 32% (99% CI 29 to 35) of variation, center location for 29% (99% CI 25 to 33), and surgical procedure or patient variables for 24% (99% CI 20 to 27). Operative time was significantly lower among experienced surgeons having practiced from 5–19 years (-21.8 min, P<0.05), performing at least 300 thyroidectomies per year (-28.8 min, P<0.05), and with increasing number of thyroidectomies performed the same day (-11.7min, P<0.001). Conversely, operative time increased in cases of procedure supervision by a more experienced surgeon (+20.0 min, P<0.001). The remaining 13.0% of variability was attributable to unanticipated technical difficulties at the time of surgery. Conclusions Variation in thyroidectomy duration is largely explained by preoperative factors, suggesting that it can be accurately anticipated. Prediction tools allowing better regulation of patient flow in operating rooms appears feasible for both working conditions and cost management.

Methodological Quality of Surgical Mortality Studies Using Large Hospital Databases: A Systematic Review.

Objective: To review the methodology employed in surgical mortality studies to control for potential confounders. Summary Background Data: Nationwide hospital data are increasingly used to investigate surgical outcomes. However, poor data granularity and coding inaccuracies may lead to flawed findings. Methods: We conducted a systematic review in accordance with the PRISMA statement in 6 major journals (NEJM, Lancet, BMJ, JAMA, Medical Care, Annals of Surgery) using PubMed from its inception until December 31, 2014. Two reviewers independently reviewed citations. Using a predesigned data collection form, we extracted information about study aim and design, data source, selected population, outcome definition, patient and hospital adjustment, statistics, and sensitivity analyses. The methodological quality of studies was assessed based on 5 criteria and explored over time. Results: Among 89 included studies from 1987 to 2014, 54 explored surgical mortality determinants, 13 compared surgical procedure effectiveness, 13 evaluated the impact of healthcare policy, and 9 described outcome trends for specific procedures. A total of 89% (n = 79) of studies did not describe population selection criteria at patient and hospital level, 64% (n = 57) did not consider secular trends, 52% (n = 46) neglected hospital clustering or characteristics, 21% (n = 19) did not perform sensitivity analyses, and 4% did not adjust outcomes for patient risk (n = 4). The percentage of studies satisfying at least 3 of these criteria increased significantly from 44% before 1999 to 52% between 2000 and 2009 and 78% after 2010 (P = 0.008). Conclusions: Although methodological quality of studies has improved over time, confounder control could be improved through better study design, homogeneous population selection, the consideration of hospital factors and secular trends influencing surgical mortality, and the systematic performance of sensitivity analyses.

Presence of Kidney Disease as an Outcome Predictor in Patients with Pulmonary Arterial Hypertension

Background: Pulmonary arterial hypertension (PAH) may lead to right heart failure and subsequently alter glomerular filtration rates (GFR). Chronic kidney disease (CKD, GFR <60 mL/min/1.73 m2) may also adversely affect PAH prognosis. This study aimed to assess how right heart hemodynamics was associated with reduced estimated GFR (eGFR) and the association of CKD with survival in PAH patients. Methods: In a prospective PAH cohort (2003–2012), invasive hemodynamics and eGFR were collected at diagnosis (179 patients) and during follow-up (159 patients). The prevalence of CKD was assessed at PAH diagnosis. Variables, including hemodynamics, associated with reduced eGFR at diagnosis and during follow-up were tested in multivariate analysis. The association of CKD with survival was evaluated using a multivariate Cox regression model. Results: At diagnosis, mean age was 60.4 ± 16.5 years, mean pulmonary arterial pressure was 43 ± 12 mm Hg, and eGFR was 74.4 ± 26.4 mL/min/1.73 m2. CKD was observed in 52 incident patients (29%). Independent determinants of reduced eGFR at diagnosis were age, systemic hypertension, and decreased cardiac index. Independent determinants of reduced eGFR during follow-up were age, female gender, PAH etiology, systemic hypertension, decreased cardiac index, and increased right atrial pressure. Age ≥60 years, female gender, NYHA 4, and CKD at diagnosis were independently associated with decreased survival. The adjusted hazards ratio for death associated with CKD was 1.81 (95% confidence interval [1.01–3.25]). Conclusion: CKD is frequent at PAH diagnosis and is independently associated with increased mortality. Right heart failure may induce renal hypoperfusion and congestion, and is associated with eGFR decrease.

Surgical Risks Associated with Winter Sport Tourism

Background Mass tourism during winter in mountain areas may cause significant clustering of body injuries leading to increasing emergency admissions at hospital. We aimed at assessing if surgical safety and efficiency was maintained in this particular context. Methods We selected all emergency admissions of open surgery performed in French hospitals between 2010 and 2012. After identifying mountain areas with increasing volume of surgical stays during winter, we considered seasonal variations in surgical outcomes using a difference-in-differences study design. We computed multilevel regressions to evaluate whether significant increase in emergency cases had an effect on surgical mortality, complications and length of stay. Clustering effect of patients within hospitals was integrated in analysis and surgical outcomes were adjusted for both patient and hospital characteristics. Results A total of 381 hospitals had 559,052 inpatient stays related to emergency open surgery over 3 years. Compared to other geographical areas, a significant peak of activity was noted during winter in mountainous hospitals (Alps, Pyrenees, Vosges), ranging 6-77% volume increase. Peak was mainly explained by tourists’ influx (+124.5%, 4,351/3,496) and increased need for orthopaedic procedures (+36.8%, 4,731/12,873). After controlling for potential confounders, patients did not experience increased risk for postoperative death (ratio of OR 1.01, 95%CI 0.89-1.14, p = 0.891), thromboembolism (0.95, 0.77-1.17, p = 0.621) or sepsis (0.98, 0.85-1.12, p = 0.748). Length of stay was unaltered (1.00, 0.99-1.02, p = 0.716). Conclusion Surgical outcomes are not compromised during winter in French mountain areas despite a substantial influx of major emergencies.

Effect of data validation audit on hospital mortality ranking and pay for performance

Background Quality improvement and epidemiology studies often rely on database codes to measure performance or impact of adjusted risk factors, but how validity issues can bias those estimates is seldom quantified. Objectives To evaluate whether and how much interhospital administrative coding variations influence a typical performance measure (adjusted mortality) and potential incentives based on it. Design National cross-sectional study comparing hospital mortality ranking and simulated pay-for-performance incentives before/after recoding discharge abstracts using medical records. Setting Twenty-four public and private hospitals located in France Participants All inpatient stays from the 78 deadliest diagnosis-related groups over 1 year. Interventions Elixhauser and Charlson comorbidities were derived, and mortality ratios were computed for each hospital. Thirty random stays per hospital were then recoded by two central reviewers and used in a Bayesian hierarchical model to estimate hospital-specific and comorbidity-specific predictive values. Simulations then estimated shifts in adjusted mortality and proportion of incentives that would be unfairly distributed by a typical pay-for-performance programme in this situation. Main outcome measures Positive and negative predictive values of routine coding of comorbidities in hospital databases, variations in hospitals’ mortality league table and proportion of unfair incentives. Results A total of 70 402 hospital discharge abstracts were analysed, of which 715 were recoded from full medical records. Hospital comorbidity-level positive predictive values ranged from 64.4% to 96.4% and negative ones from 88.0% to 99.9%. Using Elixhauser comorbidities for adjustment, 70.3% of hospitals changed position in the mortality league table after correction, which added up to a mean 6.5% (SD 3.6) of a total pay-for-performance budget being allocated to the wrong hospitals. Using Charlson, 61.5% of hospitals changed position, with 7.3% (SD 4.0) budget misallocation. Conclusions Variations in administrative data coding can bias mortality comparisons and budget allocation across hospitals. Such heterogeneity in data validity may be corrected using a centralised coding strategy from a random sample of observations.

Relaxation before Debriefing during High-fidelity Simulation Improves Memory Retention of Residents at Three MonthsA Prospective Randomized Controlled Study

Background: High-fidelity simulation is known to improve participant learning and behavioral performance. Simulation scenarios generate stress that affects memory retention and may impact future performance. The authors hypothesized that more participants would recall three or more critical key messages at three months when a relaxation break was performed before debriefing of critical event scenarios. Methods: Each resident actively participated in one scenario and observed another. Residents were randomized in two parallel-arms. The intervention was a 5-min standardized relaxation break immediately before debriefing; controls had no break before debriefing. Five scenario-specific messages were read aloud by instructors during debriefings. Residents were asked by telephone three months later to recall the five messages from their two scenarios, and were scored for each scenario by blinded investigators. The primary endpoint was the number of residents participating actively who recalled three or more messages. Secondary endpoints included: number of residents observing who recalled three or more messages, anxiety level, and debriefing quality. Results: In total, 149 residents were randomized and included. There were 52 of 73 (71%) residents participating actively who recalled three or more messages at three months in the intervention group versus 35 of 76 (46%) among controls (difference: 25% [95% CI, 10 to 40%], P = 0.004). No significant difference was found between groups for observers, anxiety or debriefing quality. Conclusions: There was an additional 25% of active participants who recalled the critical messages at three months when a relaxation break was performed before debriefing of scenarios. Benefits of relaxation to enhance learning should be considered for medical education.

Influence of observable and unobservable exposure on the patient's risk of acquiring influenza-like illness at hospital

During outbreaks of hospital-acquired influenza-like illness (HA-ILI) healthcare workers (HCWs), patients, and visitors are each a source of infection for the other. Quantifying the effects of these various exposures will help improve prevention and control of HA-ILI outbreaks. We estimated the attributability of HA-ILI to: (1) exposure to recorded or unrecorded sources; (2) exposure to contagious patient or contagious HCW; (3) exposure during observable or unobservable contagious period of the recorded sources; and, (4) the moment of exposure. Among recorded sources, 59% [95% credible interval (CrI) 34-83] of HA-ILI of patients was associated with exposure to contagious patients and 41% (95% CrI 17-66) with exposure to contagious HCWs. Exposure during the unobservable contagiousness period of source patients accounted for 49% (95% CrI 19-75) of HA-ILI, while exposure during the unobservable contagiousness period of source HCWs accounted for 82% (95% CrI 51-99) of HA-ILI. About 80% of HA-ILIs were associated with exposure 1 day earlier. Secondary cases of HA-ILI might appear as soon as the day after the detection of a primary case highlighting the explosive nature of HA-ILI spread. Unobservable transmission was the main cause of HA-ILI transmission suggesting that symptom-based control measures alone might not prevent hospital outbreaks. The results support the rapid implementation of interventions to control influenza transmission.