Implementation of the 5S-KAIZEN-TQM approach in a public hospital in Tunisia.

INTRODUCTION: The 5S-Kaizen-TQM is a step-by-step approach, originally implemented in the Japanese industry as a continuous improvement strategy. AIM: To underline the positive impact of its implementation in three pilot departments in Tunisia public hospital. METHODS: The 5S-KAIZEN-TQM introduced into three clinical departments lasted 6 months from February 2021 to July 2021. Firstly, we organized seminar to introduce this approach and training sessions on 5S and Kaizen activities to each department staff members. To collect data, we conduct satisfaction surveys, face to face interviews, meetings, and brainstorming sessions. To present these data, checklists, Analytic Hierarchy Process (AHP), Ishikawa chart, Value stream mapping (VSM) charts and visual management techniques were adopted. Then, with the participation of the staff members, we implemented the two steps of this approach and evaluated their performance by the identification of indicators related to each step and to each Departement. RESULTS: The project had positive implications on employee and patient satisfaction. 5S step activities leaded to the reduction of the item research time and the releases of space. Improving the working environment increased staff satisfaction. Kaizen activities conducted to the reduction of process lead time and the error reductions which increased patient satisfaction. CONCLUSION: This project, first in Tunisia, was undertaken by Tunisian National Health Evaluation and Accreditation Agency (INEAS) and partners as part of the program for the research on organizational innovation in health. The fundings of this project can be disseminated and perpetuated the 5S-KAIZEN-TQM approach in the health sector in countrywide.

Management of patients with cardiovascular diseases during Ramadan.

During the month of Ramadan, over one billion Muslims observe a water and food fast from sunrise to sunset. The practice of this religious duty causes marked changes in eating and sleeping habits. With the increasing incidence of cardiovascular (CV) risk factors, the number of patients with CV pathologies who wish to fast is increasing worldwide, and in Tunisia, which is ranked as a high CV risk country. If fasting has been shown to be beneficial for the improvement of some metabolic parameters, its practice in patients with CV pathology remains debated. The Tunisian Society of Cardiology and Cardiovascular Surgery (STCCCV) in consultation with the National Instance of Evaluation and Accreditation in Health (INEAS) has established this document in the form of a consensus after having analysed the literature with the aim of addressing these questions: -What is the impact of fasting in patients with CV pathologies? -How to stratify the risk of fasting according to CV pathology and comorbidities? -How to plan fasting in patients with CV diseases? -What are the hygienic and dietary measures to be recommended during fasting in patients with CV pathologies? -How to manage medication during the month of Ramadan in patients with CV diseases?

Humoral and Cellular Immunogenicity of Six Different Vaccines against SARS-CoV-2 in Adults: A Comparative Study in Tunisia (North Africa).

BACKGROUND: The mass vaccination campaign against SARS-CoV-2 was started in Tunisia on 13 March 2021 by using progressively seven different vaccines approved for emergency use. Herein, we aimed to evaluate the humoral and cellular immunity in subjects aged 40 years and over who received one of the following two-dose regimen vaccines against SARS-CoV-2, namely mRNA-1273 or Spikevax (Moderna), BNT162B2 or Comirnaty (Pfizer-BioNTech), Gam-COVID-Vac or Sputnik V (Gamaleya Research Institute), ChAdOx1-S or Vaxzevria (AstraZeneca), BIBP (Sinopharm), and Coronavac (Sinovac). MATERIAL AND METHODS: For each type of vaccine, a sample of subjects aged 40 and over was randomly selected from the national platform for monitoring COVID-19 vaccination and contacted to participate to this study. All consenting participants were sampled for peripheral blood at 3-7 weeks after the second vaccine dose to perform anti-S and anti-N serology by the Elecsys® (Lenexa, KS, USA) anti-SARS-CoV-2 assays (Roche® Basel, Switzerland). The CD4 and CD8 T cell responses were evaluated by the QuantiFERON® SARS-CoV-2 (Qiagen® Basel, Switzerland) for a randomly selected sub-group. RESULTS: A total of 501 people consented to the study and, of them, 133 were included for the cellular response investigations. Both humoral and cellular immune responses against SARS-CoV-2 antigens differed significantly between all tested groups. RNA vaccines induced the highest levels of humoral and cellular anti-S responses followed by adenovirus vaccines and then by inactivated vaccines. Vaccines from the same platform induced similar levels of specific anti-S immune responses except in the case of the Sputnik V and the AstraZeneca vaccine, which exhibited contrasting effects on humoral and cellular responses. When analyses were performed in subjects with negative anti-N antibodies, results were similar to those obtained within the total cohort, except for the Moderna vaccine, which gave a better cellular immune response than the Pfizer vaccine and RNA vaccines, which induced similar cellular immune responses to those of adenovirus vaccines. CONCLUSION: Collectively, our data confirmed the superiority of the RNA-based COVID-19 vaccines, in particular that of Moderna, for both humoral and cellular immunogenicity. Our results comparing between different vaccine platforms in a similar population are of great importance since they may help decision makers to adopt the best strategy for further national vaccination programs.

Performance Indicators and Dashboard for an Emergency Department of a Teaching Hospital.

INTRODUCTION: The quality assessment of the provided cares is an ongoing challenge for public healthcare organizations. According to a systemic overview, the performance evaluation of any system requires the identification as well as the evaluation of each of its main processes. However, addressing the performance of an emergency department is often limited to its mission of patient care. AIM: The objective of this work is to propose a tool that continually evaluates the performance of an emergency department within a teaching hospital by simultaneously considering its both vocations: (i) health care delivery to patients and (ii) skill training for learners. RESULTS: In line with the principles of continuous improvement drive andmanagement by objectives, appropriate performance indicators have been proposed for each of the two processes. In addition, a dashboard has been implemented to provide decision makers with a synthetic overview of the department performance measures. CONCLUSION: One of the major shortcomings of dashboards is the issue of data collection, input and updating. To overcome this shortcoming, it is recommended to integrate it into an information and decision-making support system that manages the entire emergency department.

Rapid diagnostic tests : Pros, cons and potential use in the COVID-19 management in Tunisia.

OBJECTIVES: Diagnosis of SARS-CoV-2 infection is a major public health issue. In a context of limited diagnostic capacity with the reference technique (real-time RT-PCR), many manufacturers have developed rapid diagnostic tests (RDTs). Although very promising in theory, these tests have raised many questions. This article is a rapid review that synthesizes data regarding different types of available RDTs, their performance, their limits and their potential indications in Tunisia as proposed by a multidisciplinary group of experts. METHODS: A literature review was carried out on the websites of international organizations, governmental bodies and on INAHTA database, completed by a search of relevant scientific articles up to 1 June 2020. The synthesis of the data was submitted to a panel of experts to propose recommendations for the Tunisian context. RESULTS: RDTs based on the detection of antigens and antibodies have sensitivity and specificity related issues. Few validation reports are published in the scientific literature. Pending more evidence on their performance and validity, several international organizations recommend their use only for research purposes. TDRs based on antibody detection are not appropriate for the early diagnosis of COVID-19. However, validated and specific tests could provide complementary diagnostic information to reference tests. CONCLUSION: Pending further evidence, the panel recommends the use of RDTs mainly for research purposes at the community level.

Disinfection booths in the context of COVID-19 pandemic.

OBJECTIVES: Industries have made claims on the effectiveness of a disinfection procedure in reducing COVID-19 transmission. This procedure is usually performed by automated dispersion of disinfectant on individuals when they go through a booth. This Health Technology Assessment (HTA) report is a systematic review that synthesizes the evidence on the efficacy and safety of using these booths and provides recommendations to the Ministry of Health to facilitate decision-making regarding the relevance of using this technology. METHODS: A systematic literature review was performed using Pubmed, Web of Science, INAHTA and GIN databases, from inception to June 4, 2020. Three independent reviewers selected eligible studies then extracted and synthesized the evidence. The synthesis was submitted to a multidisciplinary group of experts to provide recommendations. RESULTS: Two scientific papers and a Malaysian HTA report were included in data synthesis. In light of the resources consulted, spraying disinfectants on humans in booths is not effective and can be toxic. Disinfectants are intended for use on surfaces, not on living tissue and spraying disinfectants on the outside of the body does not kill the virus inside an infected person's body. Furthermore, this procedure may increase the risk of neglecting other effective measures. CONCLUSION: It is recommended to prohibit the use of disinfection booths in all structures.

[Is BNP assay useful for the diagnosis of acute dyspnea in emergencies departments?]. / Est-ce que le dosage du brain natriuretic peptide est utile dans le diagnostic de la dyspnée aiguë aux urgences?

BACKGROUND: It would be interesting to the emergency doctor to have at his disposal a helpful diagnostic tool like brain natriuretic peptide (BNP). Such assay is simple, available and reliable. AIMS: To report our experience on the role of BNP in the etiological diagnosis of acute dyspnea (AD) in emergency room (ER) and to assess the cost-effectiveness ratio of such diagnosis strategy. METHODS: A prospective study conducted in the ER of Rabta university teaching hospital of Tunis, from March 1st to June 20th 2010, involving 30 consecutive patients presenting to the emergency for AD. All patients underwent echocardiography in their acute phase and benefited from the dosage of BNP during the first 4 hours. The echocardiography parameters were collected by a single operator who was unaware of the results of the BNP dosage. RESULTS: The mean age of patients was 72.8years with a sex ratio of 1.5. AD was of orthopnea type in 9 cases and stage III NYHA dyspnea in the other patients. Clinical and radiological signs of left heart failure were noted in 30% of cases. Ultrasound data have objectified systolic dysfunction in 4 cases, diastolic in 3 cases and systolic plus diastolic in 10 cases. The BNP levels were below 100 pg/ml in 10 cases with pulmonary origin of the AD. A BNP level between 100 and 400 pg/ml was noted in 3 cases. In our study, the clinical probability of AHF prior to performing the test was estimated at 53% and estimated at 100% after the BNP assay. The BNP assay has reduced the length of stay in the emergency department 4 to 5 days and saved nearly 50% of the cost of care per patient. CONCLUSION: The BNP assay, has allowed us to confirm the AHF all cases. Given the prognostic value and economic benefit of this test we recommend its use in ER of our country.

[Tunisian survey about organ donation, attitude and opinion?]. / Don d'organes et population tunisienne, attitude et opinion ?

OBJECTIVE: In Tunisia organ donation stays very low. This is in part due to family's opposition in brain death situation. We realized a survey on a representative group of the Tunis's population (2.8 millions citizens) in the aim to clarify, among persons refusing organ donation, the prevalence of refusals determiners to individualize actions. METHODS: This survey was made in the region of Tunis between March 2006 and February 2007. The 16 questions of the survey were classified in four subjects: organ donation knowledge, opinion and attitude of the citizen, explicit justification and statements advanced in case of organ's donation refusal. RESULTS: 80.7% of citizens sounded are informed with the possibility of organ transplant in Tunisia. Only 50% of persons agree to accept organ donation after dying. Among the group refusing organ donation after dying, the absence of an understandable argument is recorded in 55.3% of cases. The violation on body integrity after death as well as religious obstruction are at the head of list of statements advanced in case of organ's donation refusal with respectively 79,9% and 63.1%. CONCLUSION: Relation researched between bodies and spirituality and individualism are the two explanations of this phenomenon of refusal of organ donation in Tunisia.