Pierre Chopard

A controlled study of inhaled pentamidine for primary prevention of Pneumocystis carinii pneumonia

BACKGROUND Current recommendations for prophylaxis of Pneumocystis carinii pneumonia (PCP) are based on data from patients who have had at least one episode of PCP (secondary prevention). We designed a study to determine the efficacy and side effects of inhaled pentamidine in the primary prevention of PCP. METHODS Two hundred twenty-three patients sero-positive for human immunodeficiency virus (HIV) who had the acquired immunodeficiency syndrome (AIDS) but not PCP, who had advanced AIDS-related complex, or who had less than 0.2 x 10(9) CD4-positive lymphocytes per liter received either 300 mg of pentamidine isethionate or 300 mg of sodium isethionate every 28 days by inhaler. The proportion of patients surviving without PCP was analyzed with the log-rank test as a function of time spent in the trial, according to the intention to treat with either placebo or pentamidine. RESULTS The third of five planned interim analyses showed a significant difference in the occurrence of PCP, with 8 cases in pentamidine group and 23 in the placebo group (nominal P value = 0.0021). There were no deaths within 60 days of the diagnosis of PCP and no significant differences in survival between groups. Approximately 53 inhalations were needed to prevent one episode of pneumonia. Thirty-eight of 114 patients given pentamidine (33 percent) and 7 of 109 given placebo (6 percent) had moderate-to-severe coughing during inhalations (two-tailed P less than 0.00001), which caused 4 patients given pentamidine (3.5 percent) to discontinue taking it. CONCLUSIONS A dose of 300 mg of aerosolized pentamidine given every four weeks was well tolerated and 60 to 70 percent effective in preventing a first episode of PCP in patients with HIV infection.

Assessment of food intake in hospitalised patients: a 10-year comparative study of a prospective hospital survey

BACKGROUND & AIMS A food quality control and improvement permanent process was initiated in 1999. To evaluate the food service evolution, protein-energy needs coverage were compared in 1999 and 2008 with the same structure survey in all hospitalized patients receiving 3 meals/day. METHODS Nutritional values of food provided, consumed and wasted over 24h including non-exclusive nutritional support were calculated individually. Nutritional needs were estimated as 110% of Harris-Benedict formula for energy and 1.2 or 1.0 g protein/kg/day for patients <65 or ≥65 years old, respectively. Multivariate analysis identified factors associated with low nutritional intake in both populations standardized to body mass index (BMI) of 1999s patients. RESULTS Out of 1677 patients, 1291 were included. Mean BMI was higher in 2008 than 1999 (P<0.001). The proportion of underfed patients was unchanged (69 vs. 70%, NS). The consumption of ≥1 oral nutritional supplements (ONS) daily increased the protein needs coverage from 80% to 115% (P<0.001). The year 1999, high BMI, 1st week of hospital stay, specific diet, ONS absence and low meal quality were associated with low nutritional intakes. CONCLUSION The nutritional needs coverage could have improved in 2008 if BMI was similar to 1999s. ONS consumption is associated with a lower risk of underfeeding in hospitalized patients.

Identifying acutely ill medical patients requiring thromboprophylaxis

*Service Quality of Care, Geneva University Hospitals and Faculty of Medicine, Geneva; Sanofi-Synthelabo (Switzerland), Meyrin; and Divisionof Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, SwitzerlandTo cite this article: Chopard P, Spirk D, Bounameaux H. Identifying acutely ill medical patients requiring thromboprophylaxis. J Thromb Haemost2006; 4: 915–6.

What is quality and how is it achieved? Practitioners’ views versus quality models

Background: Quality improvement in healthcare organisations requires structural reorganisation and systems reform, and also the development of an appropriate organisational “culture”. Beliefs and attitudes that are thought by experts to be conducive to quality improvement in hospitals include the understanding of healthcare as a complex system, recognition of the importance of coordination of healthcare processes, a positive attitude towards medical error, adherence to the concept of continuous improvement, and a central preoccupation with the patient’s welfare. Objectives: To explore the ideas about quality held by hospital-based doctors and nurses in Geneva, Switzerland. Methods: Semi-structured interviews were conducted with 21 doctors and nurses in five hospital departments to explore their ideas about the definition of quality in healthcare, their perceptions about the main barriers to achieving quality healthcare, the factors that facilitate delivery of quality healthcare, and notions of responsibility for ensuring quality healthcare. Results and conclusions: Thematic analysis of the interview data suggested that doctors’ and nurses’ ideas bear little resemblance to models of quality developed by quality experts. Study participants considered quality of care to be primarily the responsibility of individual practitioners. Quality was seen as mainly dependent on the practitioners’ mastery of the technical and interpersonal aspects of care. In contrast, the healthcare system was seen primarily as a source of obstacles to good quality care, providing insufficient resources and imposing an excessive administrative burden. The paper discusses the potential implications of these ideas for the implementation of quality management initiatives.

Measuring human-error probabilities in drug preparation: a pilot simulation study

ObjectivesDesigning a safe medication process requires the ability to model its reliability using methods such as probabilistic risk assessment (PRA). However, lack of data, especially on human-error probabilities (HEPs), limits its use. To assess whether small-scale simulations could help generate HEP data, a pilot study was conducted among nurses and anaesthetists. It focused on two core activities, namely, the manual preparation of medications and the arithmetic necessary to prepare drugs. Its specific objectives were to evaluate whether HEPs could be high enough to be measurable and to determine whether these HEPs could be sensitive to individuals and task details. These would give some insight into the level of detail required by PRA analysis.MethodsThirty nurse and 28 anaesthetist volunteers were involved in the experiment. Nurses and anaesthetists had to prepare medications for 20 patients and 22 syringes of various drugs, respectively. Both groups had to perform 22 calculations relating to the preparation of drugs. HEPs, distribution of HEPs and dependency of HEPs on individuals and task details were assessed.ResultsIn the preparation tasks, overall HEP was 3.0% for nurses and 6.5% for anaesthetists. In the arithmetic tasks, overall HEP was 23.8% for nurses and 8.9% for anaesthetists. A statistically significant difference was noted between the two groups. In both preparation and arithmetic tasks, HEPs were dependent on individual nurses but not on individual anaesthetists. In every instance, HEPs were dependent on task details.ConclusionOur study illustrates that small-scale simulations represent an interesting way of generating HEPs. HEPs are, indeed, in the range of 10−2 and 10−1. But in most cases, HEPs depend heavily on operators and task details. This dependency means that the influence of these parameters must be determined before advanced PRA analysis. There is therefore an urgent need to develop experimental research into assessing this influence by means of randomised controlled trials.

Is the Surgical Safety Checklist successfully conducted? An observational study of social interactions in the operating rooms of a tertiary hospital

Objectives To determine whether the items on the Time Out and the Sign Out of the Surgical Safety Checklist are properly checked by operating room (OR) staff and to explore whether the number of checked items is influenced by the severity of the intervention and the use of the checklist as a memory tool during the Time Out and the Sign Out periods. Methods From March to July 2010, data were collected during elective surgery at the Geneva University Hospitals, Switzerland. The main outcome was to assess whether each item of the Time Out and the Sign Out checklists have been checked, that is, ‘confirmed’ by at least one member of the team and ‘validated’ by at least one other member of the team. The secondary outcome was the number of validated items during the Time Out and the Sign Out. Results Time Outs (N=80) and Sign Outs (N=81) were conducted quasi systematically (99%). Items were mostly confirmed during the Time Out (range 100–72%) but less often during the Sign Out (range 86–19%). Validation of the items was far from optimal: only 13% of Time Outs and 3% of Sign Outs were properly checked (all items validated). During the Time Out, the validation process was significantly improved among the highest risk interventions (29% validation vs 15% among interventions at lower risk). During the Sign Out, a similar effect was observed (19% and 8%, respectively). A small but significant benefit was observed when using a printed checklist as a memory tool during the Sign Out, the proportion of interventions with almost all validated items being higher compared with those without the memory tool (20% and 0%, respectively). Conclusions Training on the proper completion of the checklist must be provided to OR teams. The severity of the interventions influenced the number of items properly checked.

A predictive score to identify hospitalized patients' risk of discharge to a post-acute care facility

BackgroundEarly identification of patients who need post-acute care (PAC) may improve discharge planning. The purposes of the study were to develop and validate a score predicting discharge to a post-acute care (PAC) facility and to determine its best assessment time.MethodsWe conducted a prospective study including 349 (derivation cohort) and 161 (validation cohort) consecutive patients in a general internal medicine service of a teaching hospital. We developed logistic regression models predicting discharge to a PAC facility, based on patient variables measured on admission (day 1) and on day 3. The value of each model was assessed by its area under the receiver operating characteristics curve (AUC). A simple numerical score was derived from the best model, and was validated in a separate cohort.ResultsPrediction of discharge to a PAC facility was as accurate on day 1 (AUC: 0.81) as on day 3 (AUC: 0.82). The day-3 model was more parsimonious, with 5 variables: patients partner inability to provide home help (4 pts); inability to self-manage drug regimen (4 pts); number of active medical problems on admission (1 pt per problem); dependency in bathing (4 pts) and in transfers from bed to chair (4 pts) on day 3. A score ≥ 8 points predicted discharge to a PAC facility with a sensitivity of 87% and a specificity of 63%, and was significantly associated with inappropriate hospital days due to discharge delays. Internal and external validations confirmed these results.ConclusionA simple score computed on the 3rd hospital day predicted discharge to a PAC facility with good accuracy. A score > 8 points should prompt early discharge planning.

Implementation of the surgical safety checklist in Switzerland and perceptions of its benefits: cross-sectional survey.

Objectives To examine the implementation of the Surgical Safety Checklist (SSC) among surgeons and anaesthetists working in Swiss hospitals and clinics and their perceptions of the SSC. Methods Cross-sectional survey at the 97th Annual Meeting of the Swiss Society of Surgery, Switzerland, 2010. Opinions of the SSC were assessed with a 6-item questionnaire. Results 152 respondents answered the questionnaire (participation rate 35.1%). 64.7% respondents acknowledged having a checklist in their hospital or their clinic. Median implementation year was 2009. More than 8 out of 10 respondents reported their team applied the Sign In and the Time Out very often or quasi systematically, whereas almost half of respondents acknowledged the Sign Out was applied never or rarely. The majority of respondents agreed that the checklist improves safety and team communication, and helps to develop a safety culture. However, they were less supportive about the opinion that the checklist facilitates teamwork and eliminates social hierarchy between caregivers. Conclusions This survey indicates that the SSC has been largely implemented in many Swiss hospitals and clinics. Both surgeons and anaesthetists perceived the SSC as a valuable tool in improving intraoperative patient safety and communication among health care professionals, with lesser importance in facilitating teamwork (and eliminating hierarchical categories).

Validation of a 15-item Care-related Regret Coping Scale for Health-care Professionals (RCS-HCP)

Validation of a 15‐item Care‐related Regret Coping Scale for Health‐care Professionals (RCS‐HCP): Delphine Sophie COURVOISIER, et al. Department of Psychology, Harvard University, USA—

Self-Rated Health and Sick Leave among Nurses and Physicians: The Role of Regret and Coping Strategies in Difficult Care-Related Situations

Moral distress – such as feeling strong regret over difficult patient situations – is common among nurses and physicians. Regret intensity, as well as the coping strategies used to manage regrets, may also influence the health and sickness absence of healthcare professionals. The objective of this study was to determine if the experience of regret related to difficult care-related situations is associated with poor health and sick leave and if coping strategies mediate these associations. Two cross-sectional surveys were conducted in Switzerland (Geneva, 2011 and Zurich, 2014). Outcomes were self-rated health (SRH) and sick leave in the last 6 months. We examined the associations of regret intensity with the most important care-related regret, number of recent care-related regrets, and coping strategies, using regressions models. Among 775 respondents, most reported very good SRH and 9.7% indicated absence from work during four working days or more. Intensity of the most important regret was associated with poor SRH among nurses and physicians, and with higher sick leave among nurses. Maladaptive emotion-focused strategies were associated with poor SRH among nurses, whereas adaptive emotion-focused strategies were positively associated with higher SRH and lower sick leave among physicians. Because care-related regret is an integral part of clinical practice in acute care hospitals, helping physicians and, especially, nurses to learn how to deal with negative events may yield beneficial consequences at the individual, patient care, and institutional level.