[Quantifying errors in the identification of patients' medical records in an active filing]. / Erreurs d'identification des patients dans un local d'archives vivantes.

The aim of this study was to quantify and qualify mistaken identities in a current medical records archive. The medical records are classified by identification indexes (day and month of birth, the first letter of their surname) by category where their placement is a function of the record's status defined as "current", "semi-current" or "dead". All of the medical records marked as "current" (n=43,592), dating between 12 February 2004 to 11 March 2004, were analysed. 1397 (3.2%) contained at least one error, totalling 1456 errors, or an average of 1.04 errors per record. The errors were classified into two types: misidentification (1254 or 86.1%) and logistical errors (202 or 13.9%). 256 serious mistakes were identified as representing 17.6% of the cases. The staff costs associated with managing these errors totalled 12,408 Euro, corresponding to a cost of 8.88 Euro per error. The immediate impact is a reduction in the workload of staff directly due to the absence of the missing file. The depth of this problem was more significant than had been suggested by the indicators, both qualitatively and quantitatively. These results should be used to advocate for the implementation of a policy on continuous quality assessment (scoring the quality of the creation of the record, and scoring the intervention).

Spatial heterogeneity of personal exposure to airborne metals in French urban areas.

The spatial distribution of urban population exposures to ambient air particles was investigated as part of the Genotox'ER study conducted in four metropolitan areas (Grenoble, Paris, Rouen and Strasbourg) in France. In each city, 60 to 90 non-smoking adult and children volunteers were selected. Subjects lived in three different urban sectors: one highly exposed to traffic emissions, one influenced by local industrial sources, and a background urban environment. The Harvard Chempass multi-pollutant personal sampler was used to sample PM10 and PM2.5 particles during 48 h during two different seasons ('hot' and 'cold'). The elemental composition of the filters was analysed by Particle-Induced X-ray Emission (PIXE). Sixteen elements were found to be over the method detection limits: Al, Si, P, S, Cl, K, Ca, Ti, V, Cr, Mn, Fe, Ni, Cu, Zn and Pb. The relative concentrations of elements of crustal origin (Si, Al, Ca) were higher in the coarse fraction of PM10 filters, while elements associated with combustion processes (traffic emissions or industrial combustion) presented higher relative concentrations in the PM2.5 fraction (S, Ni, V, Pb). Spatial heterogeneity of elemental exposures by urban sector is substantial for some metals of health concern, with 20% to 90% greater exposure values, on average, in the traffic proximity or industrial sectors, compared to the background sector, for Fe, Zn, Cu, V and Cr. This spatial heterogeneity should not be overlooked in epidemiological or risk assessment studies.

Assessment of transpulmonary absorption of ethanol from alcohol-based hand rub.

BACKGROUND: Alcohol-based hand rubs (ABHRs) have been associated with a reduction of nosocomial infections. Despite the worldwide introduction of these products in health care settings, the aim of this study was to assess the transpulmonary absorption of ethanol contains in ABHRs used by health care workers (HCWs) in real conditions of work shift. METHODS: Twenty-six HCWs of Nancy University Hospital were included. Research consisted in monitoring participants during 4 hours of work shift to assess their exposure to ethanol. The measurement of ethanol vapors in exhaled breath was performed using a class B ethylometer (Alco-Sensor FST). Ethanol concentration in inhaled breath was measured using Gilian pump LFS-113. Concentration of ethanol, acetaldehyde, and acetate in blood and urine samples were determined using gas chromatography with flame ionization detector. RESULTS: Participants were 12% male and 88% female. The mean age was 40 ± 8 years. None of the employees included in the study presented any traces of ethanol or its metabolites in the blood or urine. Ethanol (0.08 ± 0.07 mg/L) was detected in the breath of 10 HCWs at 1 to 2 minutes postexposure. The mean concentration of ethanol in the inhaled air was 46.2 mg/m. CONCLUSION: Absorption of ethanol vapor from ABHRs among HCWs during their care activities was not detected. Quantification of ethanol fumes inhaled during 4 hours of work shift was below the regulatory limitations of exposure to ethanol.

Screening for surgical nosocomial infections by crossing databases.

UNLABELLED: Surgical site infection (SSI) is a major cause of morbidity and mortality, and they are the third cause of nosocomial infections. It has been shown that surveillance can reduce the rate of these infections because the publication of the results that introduce a interrogation on her surgical pratices. However, surveillance requires considerable medical resources. Our objective is to validate a computer algorithm that uses microbiological results and the results of a C-reactive protein (CRP) assay and granulocyte count to detect SSIs. MATERIALS AND METHODS: All patients who underwent colorectal surgery between the 1st of January and the 30th of June 2009 were included. Administrative, surgical and microbiological data and the appearance of neutrophilia and CRP after surgery and during hospitalization were collected. The algorithm uses four biological variables: CRP, neutrophils, and the bacterium found on the positive sample. The CRP and neutrophil variables were coded in 0 or 1. CRP was coded as 1 if the sample was below 5mg/l at the time of the operation and increased to more than 60mg/l in the 30 days immediately after post-operation. Neutrophils were coded as 1 if the sample was normal at the time of the operation and increased to more than 12,000cells/mm(3) in the 30 days immediately after post-operation. The "type of sample" and "bacterium" variables were coded in categories. For the type of sample, we coded 3 if the sampling site was related to the surgical site, 2 if the sampling site was potentially linked to the surgical site, 1 if the sampling site was not directly or indirectly related to the surgical site and 0 if there was no sample. Regarding the bacteria, we coded 3 for bacteria found in over 5% of SSIs, 2 for bacteria found in 2-5% of SSIs, 1 for bacteria found in less than 2% of SSIs and 0 if there were no bacteria. The algorithm calculates a score from 1 to 5. RESULTS: Our study included 195 operations, out of which it was possible to study 168. Following the operations, we found neutrophilia above 12,000cells/mm(3) in 41.5% of cases and CRP above 60mg/l in 64.6% of cases. Thirty-seven operations (22%) were complicated by an SSI. The positive predictive values and the negative predictive values in our algorithm were 74.07% and 87.94%, respectively, and the number of records that remain to be investigated is 27 out of 168. CONCLUSIONS: Linking databases from bacteriology and biology with those containing the hospital records of surgical procedures is a simple method for identifying surgical nosocomial infections.

Emergence of hand contamination with Aspergillus during demolition work.

Hand rubbing with hydro-alcoholic solutions prevent the exogenous nosocomial infection, but the hydro-alcoholic solutions were not sporicidal. A major program of demolition was organized on the area of the University Hospital of Nancy (France) between 2007 and 2010, and this period is often considered as a possible source of suspending Aspergillus spores. This study shows the emergence of Aspergillus on the hands of the medical students during demolition period despite the same quality of hand hygiene.

Assessment of exposure to ethanol vapors released during use of Alcohol-Based Hand Rubs by healthcare workers.

BACKGROUND: Despite the increasing use of Alcohol-Based Hand Rub solutions, few studies have quantified the concentrations of inhaled ethanol. OBJECTIVE: The aim of this study was to assess ethanol exposure during hygienic and surgical hand disinfection practices. METHOD: Ethanol concentrations were measured at the nose level of a wooden dummy and human volunteers. Two systems were used in parallel to determine short-term ethanol vapor exposures: activated charcoal tubes followed by gas chromatography analysis and direct reading on a photoionization detector (PID). Exposure was assessed for 4 different sequences (N=10) reproducing hand rubs for simple surgery, nursing care, intensive care and surgical scrub. RESULTS: The ethanol concentrations measured were of a similar order between the dummy and volunteers. The concentrations obtained by PID were higher than the gas chromatography values for the simple care (45%) and nursing care (27%) sequences and reflected specific exposure peaks of ethanol, whereas ethanol concentrations were continuously high for intensive care (440 mg m(-3)) or surgical scrub (650 mg m(-3)). CONCLUSION: Ethanol concentrations were similar for these two exposure assessment methods and demonstrated a relationship between handled doses and inhaled doses. However, the ethanol vapors released during hand disinfection were safe for the healthcare workers.

Prospective observational study to assess hand skin condition after application of alcohol-based hand rub solutions.

BACKGROUND: The use of alcohol-based hand rub solutions (ABHRSs) in health care settings has been associated with increased hand hygiene compliance and reduced rates of nosocomial infection. Deterioration in hand skin condition leads to impaired barrier function, changes in skin flora, and increased bacterial shedding. Thus, poor skin condition can increase the risk of infection. This study evaluated the hand skin condition and dermal tolerance among health care workers (HCWs) after ABHRS application. METHODS: The study group comprised 231 HCWs (34% nurses, 22% nurse assistants, and 15% hospital cleaners). The mean participant age was 40 years. Stratum corneum hydration and superficial sebum content and surface pH of the skin were measured on the back and palm of each participant's dominant hand before and after ABHRS use. A self-assessment questionnaire was administered to collect information about the participants, their skin problems, and their perception of the ABHRS. RESULTS: The study group was 83% females. Skin hydration at the 2 assessment sites was markedly increased after ABHRS use (P < .0001). The mean pH value did not change significantly on the back of the hand, but did change significantly on the palm (P = .012). The superficial sebum content decreased significantly on the palm (P < .0001), but not on the back of the hand. HCWs reported excellent or good skin tolerance of ABHRS in 73% of cases. CONCLUSION: ABHRSs are well tolerated and do not dry the skin. pH and superficial sebum values decreased slightly, but these decreases did not affect skin barrier function. Values remained within the physiological range.

Health effects of disinfection by-products in chlorinated swimming pools.

Increased attendance at swimming pools is correlated with higher input of organic and minerals pollutants introduced by swimmers in the swimming pool water. In most swimming pools, microbiological control is performed by disinfection with the addition of chlorine. Chlorine is now well-known to lead to the formation of many disinfection by-products (DBPs) including trihalomethanes and chloramines. The hypothesis of a link between the presence of eye and skin irritation syndromes in swimmers and contact with swimming pool water treated with chlorine was initially proposed by Mood (1953). During recent decades many epidemiological studies have described the importance of DBPs generated with natural or imported organic matter present in water. Many of these DBPs are suspected to be toxic or even carcinogenic. Trihalomethanes and haloacetic acid families are the most studied but others DBPs, like chloral hydrate, haloacetonitriles, N-nitrosodimethylamine and the bromate ion, are emerging compounds of interest. Epidemiological data about the risk of cancer are still controversial. However, numerous publications highlight a toxic risk especially the risk of allergy and respiratory symptoms for babies and elite swimmers. The few publications dedicated to risk assessment do not suggest increased risk, other than for elite swimmers. These publications are likely to underestimate the risk associated with DBPs because of the lack of data in the literature precludes the calculation of risk associated with certain compounds or certain pathways. Thus for regulations, the need to take into account the risks associated with disinfection by-products is now important without forgetting the need of the control of microbiological hazards in swimming pools.

Identifying possible deaths associated with nosocomial infection in a hospital by data mining.

BACKGROUND: Nosocomial infection (NI) is a cause of patient morbidity and mortality. Conducting an audit of deaths due to NI is a potentially useful approach to improving professional standards. In France, these deaths are required to be reported, but the reporting is left to clinicians, who often do not comply. The aim of the present study was to assess whether linking the microbiological database with the hospital mortality database might be a suitable surveillance approach for identifying patients who died with an NI. METHODS: A total of 1,726 deaths were recorded in the mortality database of a French university hospital between September 1, 2006, and September 16, 2007. During this same period, 6,290 potential NIs (PNIs) were identified by bacteriological examination. These PNIs were generated using a computer algorithm specific to the bacteriology database. PNI information request forms were sent to the senior doctor of the unit where the samples had been obtained to determine whether the PNI was an NI, colonization, or a non-nosocomial infection. A total of 364 cases were common to both databases; from these, a sample of 135 cases was selected for further analysis. To establish the strength of evidence for NI as the cause of death, the 135 cases were analyzed using the patient record by an investigator from the hospital hygiene team. RESULTS: During the study period, no deaths associated with NI were reported spontaneously. Of the 135 cases analyzed, NI was considered the main cause of death in 6 (4.4%) and a contributory factor in 51 (37.8%). Thus, NI was estimated to be the main cause of death in 0.9% of all patients who died in the hospital during the study period and a contributory cause in another 8.0% of these patients. CONCLUSION: Linking databases from bacteriology with those containing hospital mortality records is a simple, reproducible tool for identifying the number of deaths attributable to NI. This may provide a powerful approach to help reduce the burden of disease due to NI through the auditing of such identified deaths.

Impacts of two perfluorinated compounds (PFOS and PFOA) on human hepatoma cells: cytotoxicity but no genotoxicity?

Perfluorinated compounds (PFCs) and particularly two of them, perfluoroctanoate (PFOA) and perfluorooctanesulfonate (PFOS), have been widely produced and used since 1950. They both persist in the environment and accumulate in wildlife and humans. The toxicity of PFOS and PFOA has been studied extensively in rodents with several adverse effects mainly a hepatocarcinogenic potential. Carcinogenic effects are not highlighted in humans' studies. In this study, we investigated the cytotoxic and genotoxic effects of PFOA and PFOS using human HepG2 cells after 1 or 24h of exposure. The cytotoxic and genotoxic potential was evaluated by MTT assay, single cell gel electrophoresis (SCGE) assay and micronucleus assay respectively. We measured the intracellular generation of reactive oxygen species (ROS) using dichlorofluorescein diacetate to identify a potential mechanism of toxicity. We observed a cytotoxic effect of PFOA and PFOS after 24h of exposure starting from a concentration of 200 µM (MTT: -14.6%) and 300 µM (MTT: -51.2%) respectively. We did not observe an increase of DNA damage with the comet assay or micronucleus with the micronucleus assay after exposure to the two PFCs. After 24h of exposure, both PFOA and PFOS highlight a decrease of ROS generation (-5.9% to -23%). We did not find an effect after an hour of exposure. Our findings show that PFOA and PFOS exert a cytotoxic effect on the human cells line HepG2 but nor PFOA or PFOS could induce an increase of DNA damage (DNA strand breaks and micronucleus) or reactive oxygen species at the range concentration tested. Our results do not support that oxidative stress and DNA damage are relevant for potential adverse effects of PFOA and PFOS. These results tend to support epidemiological studies that do not show evidence of carcinogenicity.

Factors determining poor practice in alcoholic gel hand rub technique in hospital workers.

BACKGROUND: Hand hygiene of healthcare personnel is one of the most important interventions for reducing transmission of nosocomial pathogens. Previous studies have demonstrated that the use of alcohol-based hand gel increases hand hygiene compliance, but that effective use of this product cannot be taken for granted. OBJECTIVE: Evaluate factors associated with poor hand hygiene effectiveness of hospital workers using an alcohol-based hand gel and the effect of an education program. DESIGN: A direct observational prospective study of hand hygiene effectiveness prior to training and immediately after training. SETTING AND SUBJECTS: 3067 hospital workers of different professional categories in several hospital units in the University Hospital of Nancy (France). RESULTS: Time after program start (OR 0.97, 95%CI 0.96-0.97) and being female (OR 0.37, 0.24-0.58) were highly associated with increased effectiveness of hand hygiene prior to training. Wearing rings other than a wedding ring (OR 1.8, 1.2-2.7), a bracelet (OR 2.0, 1.1-3.6), a watch (OR 1.9, 1.3-2.9) and having long nails were associated with ineffective hand rub use. Professional background was also a strong predictor with nurses and especially senior nurses demonstrating much better effectiveness than all other professional groups. Wearing wedding rings or long sleeves, and having varnished nails, visibly dirty hands prior to washing and cutaneous lesions were not associated with effective gel use. CONCLUSION: These results demonstrate that an educational program can significantly improve the proper practices for using hand rub and hand washing compliance. This study has also demonstrated that wearing rings, bracelets, watches and long nails impair hand gel application but that wedding rings, long sleeves and varnished nails do not. The finding of that hand hygiene effectiveness increased with time even prior to training indicates that knowledge gained by staff trained early diffused into those who had not yet been trained.

Short-term assessment of training of medical students in the use of alcohol-based hand rub using fluorescent-labeled hand rub and skin hydration measurements.

This study evaluated 2 measurements of the effectiveness of alcohol-based hand rub application: skin hydration and percentage of skin area covered by fluorescent-labeled hand rub. The use of fluorescent-labeled hand rub is an effective and rapid way to assess the effectiveness of hand rub application and correlates well with the effectiveness of hand hygiene technique, as evaluated by microbial counts on the hands. Measurement of skin hydration also is correlated with effectiveness of coverage and is useful in demonstrating that alcohol-based hand rub does not dehydrate the skin.

A prospective study of the impact of colonization following hospital admission by glycopeptide-resistant Enterococci on mortality during a hospital outbreak.

BACKGROUND: This study was designed to investigate the impact on mortality of colonization by glycopeptide-resistant Enterococci (GRE) during hospitalization. METHODS: Between 2004 and 2006, a hospital in Nancy, France, was subject to a GRE van A outbreak. Some 113 patients who had acquired GRE after hospital admission were matched with 113 controls. Basic demographic data, such as sex, age, principal pathology, history of surgery, and presence of associated pathology, were obtained for each case and control. Information on whether or not the case subject was still alive was obtained by searching the hospital mortality database and the civil death register and by phoning the patient's home. Statistical analysis used the Cox proportional hazards model for calculating survival function with SPSS software version 9.1 (SPSS Inc., Chicago, IL). RESULTS: The mean age was 71.2 in the GRE+ group and 70.8 in the control group (P = .80). There was a significant difference between the groups for severity status health (P = .035). The mortality rate was 30.1% in the case group and 19.5% in the control group. Single predictor variable analysis showed a hazard ratio of death in the case group of 4.61 (95% confidence interval [CI]: 2.58-8.28], P = 2 x 10(-7)). The final Cox regression model with multiple predictor variables showed that only GRE presence (OR, 1.63 [95% CI: 1.04-2.57], P = .035) and severity of comorbidity (P = .013) were independently significant predictors of mortality. CONCLUSION: This study shows that the GRE acquisition has a poor prognosis and that this is independent of the other prognostic factors such as age and severity of underlying disease. Survival in GRE+ patients was significantly shorter.