[Avoidable hospitalizations: the sole responsibility of primary care?]. / Hospitalisations potentiellement évitables: une responsabilité des seuls soins de premier recours?

BACKGROUND: Avoidable hospitalizations are used as a performance indicator of primary care in many countries. We investigate here the validity and usefulness of this measure both at a global scale and for the French healthcare system. METHODS: A scoping study was performed to take a critical look at this concept. The different uses of avoidable hospitalizations as an indicator have already been reported in two recent systematic literature reviews. RESULTS: Rates of avoidable hospitalizations seem to be far more correlated with the socioeconomic attributes of patients than with primary care supply. The few studies conducted in France confirm this international trend. Several weaknesses have been spotted in the building of this indicator: the choice of conditions that can be considered as sources of avoidable hospitalizations, their identification among hospitalization disease codes, the quality of hospital coding procedures, the ecological bias in the data collection of illustrative variables. CONCLUSION: Guidelines for improvement of this indicator are provided. In particular, we discuss the possibility of its use at the scale of the whole healthcare system.

[Emergencies and general practitionners. Which prospects? Which education?]. / Urgences et médecins de premier recours: quelles perspectives? Quelle formation?

Professionalisation of emergency medicine and triage before most of emergency consultations led to a major reduction in exposure of general practitionners (GP) to vital emergencies, which participates in reduction of their aptitudes to manage such emergencies. The risk for a GP to face a vital emergency is weak nowaday, but did not totaly disappear. Therefore, it seems important for the GPs to maintain the skills required to manage these emergencies properly. These skills would be capacity in recognizing symptoms and signs of alarm (red flags), applying life support, and sorting the patients correctly. These skills will be all the more important in the future, while the role of the GP could be reinforced in response to requirement of increased efficiency.

Identifying and preventing adverse drug events in elderly hospitalised patients: a randomised trial of a program to reduce adverse drug effects.

OBJECTIVES: Evaluate the impact of educational intervention in decreasing ADEs in elderly patients in a hospital setting. DESIGN: Randomised prospective study. SETTING: The study was performed in France in the Paris area, in 16 rehabilitation geriatric centres of APHP (Assistance Publique - Hôpitaux de Paris). Patient capacity per centre varied from 15 to 57 with a total of 526. PARTICIPANTS: All the patients > or = 65 years hospitalized during the 4 week study period were included. MEASUREMENTS: During a first 2 week phase without intervention ADE's were recorded in all centres. Then units were then randomised for an educational intervention or not. The educational phase lasted 1 week, without ADE tracking. Then, both types of units (I+ and I-) recorded ADEs for 2 weeks. Possible drug-related incidents were detected using a standardized check list (nurses) and a weekly review of all charts by investigators. Possible drug-related incidents were analysed by a group of reviewers selected from the authors to classify them as ADE or not. RESULTS: 576 patients (mean age: 83.6 +/- 7.9 years) were consecutively included. The mean number of drugs at inclusion was 9.4 +/- 4.24 drugs per patient. 223 out of 755 events were considered "probable" ADEs (29.5%). Among the 223 ADEs, 62 (28%) could have been prevented. The main outcome of this trial was the change in the proportion of ADEs in elderly patients in the intervention-units, compared to the control group. The main errors were: to high a dose (26%), double therapy (21%), under dose (13%), inappropriate drug (13%), drug-drug interaction (6%), previous same adverse drug reaction (3%) and miscellaneous (11.18%). After a specific educational intervention program, there were fewer ADEs in the intervention group (n = 38, 22%) than in the control group (n = 63, 36%; p = 0.004). CONCLUSION: Educational programs could help reduce the prevalence of ADEs by 14% and encourage physicians to change outdated prescription habits.

Development and implementation of a leadership skills course for the charge nurse.

Formal education in leadership behaviors and skills is paramount to the development of staff nurses as effective leaders. The need for effective leadership during the present transformation of healthcare, and the Joint Commission for Accreditation of Health Care Organization's mandate to educate and train staff as appropriate to their job responsibilities, resulted in the development and implementation of a leadership skills course for the staff charge nurse. A literature review, input from experienced charge nurses, and clinical nurse managers' perspectives of what is effective leadership for a charge nurse played key roles in development and implementation of the course.