P. François

Factors and outcomes associated with physicians' adherence to recommendations of infectious disease consultations for inpatients

OBJECTIVES Solicited consultations constitute a substantial workload for infectious disease specialists (IDSs). The impact of physician adherence to recommendations on clinical outcomes following solicited IDS consultations has not been previously studied. The objectives of the study were to identify the factors associated with adherence and to determine whether adherence to recommendations was associated with better clinical outcomes. METHODS A prospective study was conducted on 621 patients, aged > or = 18 years, hospitalized in a university-affiliated hospital in France, who received an IDS consultation between December 2007 and June 2008. The main outcome was early clinical improvement, and the secondary outcomes were length of stay and in-hospital mortality. RESULTS Adherence to the IDSs recommendations was 88.2% (548/621) for antimicrobial treatment and 72.2% (317/439) for diagnostic or monitoring tests. In a multivariable analysis, independent factors of adherence to therapeutic recommendations were a community-acquired infection [adjusted odds ratio (OR), 1.8; 95% confidence interval (CI), 1.1-3.0] and discontinuation or non-use of antibiotic treatment (adjusted OR, 9.7; 95% CI, 1.2-80.3). Adherence to recommendations for antibiotic treatment was associated with a higher rate of early clinical improvement (60.7% versus 43.9%, P = 0.01), shorter median length of stay (20 days versus 23 days, P = 0.03) and comparable in-hospital mortality (7.7% versus 5.5%, P = 0.50). CONCLUSIONS Factors associated with non-adherence must be anticipated by IDSs during consultations, because non-adherence leads to worse clinical outcomes. Further studies are needed to identify the interventions that could improve physician adherence to recommendations made during solicited consultations.

Implantation d’une démarche qualité dans les services médicaux d’un hôpital universitaire : facteurs d’accélération et de frein

BACKGROUND The aims of this study were to assess the level of implementation of continuous quality management program and to identify the factors associated with its failure in the medical departments of a teaching hospital. METHODS Semi-directive interviews were conducted with 52 hospitalists, including 16 department heads and 36 staff members in charge of quality management, in 30 medical departments that implemented a continuous quality management program from 1998 to 2002. The interviews were analyzed using a manual thematic method and a computerized semantic method. RESULTS At the study endpoint (i.e., 2003), the continuous quality management program was still working in six departments and was stopped in 24 departments. The professionals complied with the model of intervention based on the identification and the resolution of department problems by multiprofessional working groups. The main external factors associated with the failure of the continuous quality management program included shortage in staff and the lack of time to devote to this activity. In addition, professionals cited the defect of commitment by the top management, the lack of acknowledgment of their efforts, and the hospital accreditation as factors with negative impact on staff motivation. The main internal factors associated with the failure of the continuous quality management program were related to the leadership in quality management. The personal involvement of the department head played a key role in the continuation of the quality management program. Most of the staff regretted the lack of involvement of the physicians and stated that methodological support was needed. CONCLUSION The implementation of quality management in the medical departments remains difficult in the absence of institutional support. The leadership within the department plays a major role in the continuation of the process.

Evaluation of glycopeptide prescription and therapeutic drug monitoring at a university hospital

Abstract The aim of this study was to assess the appropriateness of glycopeptide prescription almost 15 y after the publication of the Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines. We also assessed the adequacy of dose regimen and therapeutic drug monitoring (TDM). All glycopeptide prescriptions were collected during a 3-month prospective study and evaluated by 2 independent infectious diseases experts. Appropriateness of prescription was assessed according to local guidelines based on the HICPAC recommendations. A total of 154 prescriptions were evaluated: 77% (69.1–83.0) were appropriate and 36% (28.2–43.8) were adequate with regard to dose regimen and loading dose. Multivariate analysis showed greater appropriateness for vancomycin than for teicoplanin (p=0.01). There was a wide discrepancy among units (p=0.04). TDM was appropriately performed in 40% (32.3–47.7) of glycopeptide treatments. When required, dose regimen adaptations occurred in 58% of cases. In conclusion, we show a satisfactory appropriateness of glycopeptide prescription. However, the adequacy of dose regimens must be improved. Finally, TDM does not comply with recent recommendations in most cases.

Infectious disease specialist telephone consultations requested by general practitioners

Abstract Background: Infectious diseases (ID) make up a substantial part of a general practitioners (GPs) workload. GPs frequently solicit ID specialists requesting advice on managing their patients with ID. The objectives of this study were to examine GP reasons for soliciting ID consultations and to assess the GPs’ and specialists’ opinions of the ID consultation service. Methods: This was a prospective study of consecutive solicited ID consultations requested by GPs from the ID specialists of a 2200-bed university-affiliated hospital, conducted between October 2008 and March 2009. Data related to GP characteristics, their reasons for requesting the consultation, the recommendations given by the specialists, and the specialists’ perceptions of the exchange were collected. GPs were asked to report their adherence to recommendations and their perceptions of the consultations. Results: A mean of 57 telephone consultations per month were requested by GPs during the study period. ID specialist recommendations were related to antibiotic treatment (66.2%), diagnostic or monitoring tests (46.5%), and a subsequent formal consultation or hospitalization (29.6%). The reasons reported for GPs requesting an ID consultation were related to patient management (96.5%), rapidity of access (86.3%), and quality of care improvement (84.2%). GPs were satisfied with the telephone consultations in 97.9% of cases and ID specialists in 94.7%. Conclusions: Telephone consultations with ID specialists were widely appreciated by GPs, probably due to the accessibility of these specialists. Further study is needed to assess the effects of these telephone consultations on quality of care.

CD-ROM continuous medical education model for the management of urinary tract infections in family practice

OBJECTIVES This study had for aim to assess the acceptability of a model for continuing medical education, to improve the implementation of best practice recommendations for family practice. The training focused on the management of community acquired urinary tract infections in adults. The secondary objective was to identify barriers in the implementation of these best practice recommendations. METHODS We conducted a prospective qualitative study. The intervention included an initial knowledge test, an audio-visual CD-ROM presentation, and a second knowledge test. After the session, family practitioners (FP) were asked to answer a face-to-face questionnaire in order to give their opinion on the training session. Ten FP, working in the Savoie and Isère sub-divisions in France, were included. RESULTS All FP were satisfied with the e-learning training session. The element of the session, they best appreciated, was the audio-visual presentation. The comparison between initial and second test results showed a non-significant improvement of knowledge (P=0.07). The barriers, most frequently mentioned for knowledge and use of best practice recommendations, were: lack of time, content unfit for family practice, habits, and the very broad field of expertise required. CONCLUSION FP accepted this model of continuing medical education. E-learning seems relevant to improve the implementation of best practice recommendations in family practice.

J-06 Consultation mobile d’infectiologie : description de l’activité et impact clinique

Contexte La consultation mobile d’infectiologie (CMI) est un des outils utilises par notre centre hospitalier dans le cadre du bon usage de l’antibiotherapie. Depuis decembre 2007 et pour une duree de 1 an, nous evaluons l’impact de cette CMI dont nous presentons ici les resultats intermediaires. Methode L’ensemble des conseils dispenses par la CMI a ete recense. Tous les avis concernant des patients hospitalises etaient suivis d’une evaluation entre la 48e et la 96e heure par un medecin independant de la CMI. Il analysait l’evolution des patients et l’observance aux avis therapeutiques et aux conduites diagnostiques proposees. Resultats 732 avis ont ete donnes par la CMI entre le 6 decembre 2007 et le 5 janvier 2008. 39 % des conseils concernaient des patients hospitalises et 61 % des patients externes au CHU. Les avis externes etaient demandes par des medecins liberaux dans 49 % des cas, des particuliers dans 35 % des cas, des medecins exercant dans des hopitaux peripheriques et cliniques dans 13 % des cas. Les motifs de consultation concernaient une question therapeutique ou une aide au diagnostic dans plus de la moitie des cas (54 %). Les autres demandes concernaient des conseils pour le voyage, des accidents d’exposition aux liquides biologiques et des questions diverses (vaccinations, informations generale). En ce qui concerne les patients hospitalises, la CMI etait aussi souvent interpellee en medecine qu’en chirurgie (respectivement 48 % et 52 %). Parmi les 221 patients beneficiant d’une evaluation, l’observance aux propositions therapeutiques etait de 82 %, celle aux conduites diagnostiques proposees de 87 %. Conclusion La CMI est largement sollicitee tant a l’exterieur du CHU que par les medecins du CHU. L’observance aux conseils est particulierement elevee tant pour les propositions diagnostiques que therapeutiques.