[Perception and communication of medical risk which implications for preoperative anaesthetic consultations?]. / La perception et la communication du risque médical. Quelles implications pour les consultations préanesthésiques?

Informing patients about available treatments, their advantages and disadvantages, as well as the associated risks, is critical to obtain an informed consent and is the responsibility of physicians, including anaesthesiologists. However, risks issues are not systematically discussed during anaesthesia consultations or are addressed in a vague and incomplete way. In order to improve communication and the quality of the informed consent, it is therefore essential to scrutinize problems linked to communication about risks. This article is based on a review of French and English literature on perception and communication about medical risks. Its objectives are for the one hand to summarize the main difficulties concerning risk communication in medicine and, on the other hand, to offer tools that can foster quality communication with patients especially during anaesthesia consultations.

Six years of public health surveillance of measles in France.

Data provided by the Sentinel General Practitioners (SGP) to the French Communicable Diseases Computer Network (FCDN) have been used to present the epidemiological characteristics of measles observed during a 6-year period in France. The estimated annual incidence rates per 100,000 population were 376 in 1985, 603 in 1986 and 983 in 1987, then declined during the following 3 years to 297, 258, and 263 per 100,000 population in 1988, 1989 and 1990 respectively. There is a marked seasonal change with a high early summer peak. The mean age among the cases for the 6 years of study varied from 5.4 to 6.0 years. There is an increase in the percentage of cases with a past history of measles vaccination, from 6.7% in 1985 to 12.8% in 1990. This increase may be interpreted as a consequence of a substantial increase of the vaccine coverage during the same period.

Acceptability of identification bracelets for hospital inpatients.

OBJECTIVE: To evaluate whether hospitalised patients would agree to wear an identification bracelet and whether patient acceptability is improved by more detailed explanations or by using a code instead of a name on the bracelet. DESIGN: Patient survey that tested two variables in a randomised factorial design. Explanations about identification bracelets were given (a) with or without examples of situations where patient identification may be important, and (b) with the patient name or an anonymous code appearing on the bracelet. SETTING: Swiss teaching hospital where wearing of identification bracelets was not systematic. PARTICIPANTS: Adult patients discharged from hospital (n = 1411). MAIN OUTCOME MEASURES: Patients' responses to the questions: (a) should the hospital introduce a compulsory identification bracelet? and (b) would the patient agree to wear such a bracelet? RESULTS: Globally, 83.9% of patients thought that the hospital should introduce bracelets and 90.2% stated that they would agree to wear one. Providing examples increased support for both the hospital policy (87.9% v 79.2%, p<0.001) and personal acceptance (92.2% v 88.1%, p = 0.015). Whether or not the bracelet carried the patient's name or an anonymous code did not influence patient choice. CONCLUSIONS: The majority of patients were in favour of wearing an identification bracelet during their hospital stay. This proportion increased significantly when an explanation based on examples of the consequences of incorrect patient identification had been provided.

Voluntary reporting system in anaesthesia: is there a link between undesirable and critical events?

BACKGROUND: Reporting systems in anaesthesia have generally focused on critical events (including death) to trigger investigations of latent and active errors. The decrease in the rate of these critical events calls for a broader definition of significant anaesthetic events, such as hypotension and bradycardia, to monitor anaesthetic care. The association between merely undesirable events and critical events has not been established and needs to be investigated by voluntary reporting systems. OBJECTIVES: To establish whether undesirable anaesthetic events are correlated with critical events in anaesthetic voluntary reporting systems. METHODS: As part of a quality improvement project, a systematic reporting system was implemented for monitoring 32 events during elective surgery in our hospital in 1996. The events were classified according to severity (critical/undesirable) and nature (process/outcome) and control charts and logistic regression were used to analyse the data. RESULTS: During a period of 30 months 22% of the 6439 procedures were associated with anaesthetic events, 15% of which were critical and 31% process related. A strong association was found between critical outcome events and critical process events (OR 11.5 (95% confidence interval (CI) 4.4 to 27.8)), undesirable outcome events (OR 4.8 (95% CI 2.0 to 11.8)), and undesirable process events (OR 4.8 (95% CI 1.3 to 13.4)). For other classes of events, risk factors were related to the course of anaesthesia (duration, occurrence of other events) and included factors determined during the pre-anaesthetic visit (risk of haemorrhage, difficult intubation or allergic reaction). CONCLUSION: Undesirable events are associated with more severe events and with pre-anaesthetic risk factors. The way in which information on significant events can be used is discussed, including better use of preoperative information, reduction in the collection of redundant information, and more structured reporting.

[Blood transfusion and quality assurance]. / Transfusion sanguine et assurance de la qualité.

Administrating safe blood products and being able to produce the evidence of procedures correctly employed, is today vital for healthcare professionals. Industrial quality assurance is an appropriate answer to this problem. Indeed, this approach allows the mastering of a processing system thanks to the combination of three elements: a detailed description of processes, control mechanisms and corrective measures. It relies on an information system and must be applied to all steps of blood transfusion.

[Preventing deficiencies in the transfusion process]. / La prévention des défaillances du processus transfusionnel.

The methods of system reliability analysis represent an interesting set of tools used to follow the so-called "transfusion process", defined as all the steps from donors sensitization to recipients follow-up. FMECA, (Failure Mode Effects and Criticality Analysis), can be used as a prevention tool, independently of any dysfunction in the process. Of course, it can equally be used following a failure, in order to analyse the causes and to apply the specific corrections. Quality insurance, system reliability analysis, epidemiologic surveillance and safety monitoring operate in synergy. These three issues pertaining to transfusion safety constitute a dynamic system.

[Improvement of transfusion safety in a health care service through the implementation of a quality program]. / Amélioration de la sécurité transfusionnelle dans un établissement de santé par le développement d'une démarche qualité.

The quality policy brings with it an efficient method as well as relevant tools to improve transfusion safety in health care services. This article illustrates the details of the approach through the presentation of a project developed in the East Picardie region throughout several hospitals. It underlines the importance of the choice of a good reference system, of a pertinent method and the necessity of a real project management. Furthermore, the follow-up of the project has enabled us to identify a certain number of success criteria in the steering of the changing process.

[Immunologic risks of blood transfusion and public health]. / Risque immunologique en transfusion sanguine et santé publique.

The general objective is the study, through scientific approaches, of the main components of immunological risks linked to red blood cell transfusions, as well as their consequences, in order to define precise rules for prevention, taking into account that 2,700,000 units were transfused in 1992. To reach this general aim, five intermediary objectives have to be achieved: 1) The sentinel study of the methodology used to collect information about transfusion accidents, as well as their identification and their early clinical expression; 2) The analysis of the occurrence mechanisms of incompatibilities and transfusion accidents; 3) The up-date definition of post-transfusion alloimmunization, in particular regarding 3 parameters: a) the immunogenicity of the different erythrocyte antigens, that will have to be reassessed; b) the modes of occurrence of post-transfusion anti-erythrocyte alloimmunization; c) the different types of chronology in the appearance and the persistence of anti-erythrocyte antibodies. 4) The search for significant criteria in order to assess the immunopathological correlations of the consequences of antigen-antibody conflicts; 5) The elaboration of the principles for tests evaluation and identification of the techniques linked to blood groups and the study of anti-erythrocyte antibodies.

[Quality assurance and prevention of immuno-hemolytic incidents in blood transfusion]. / Assurance de la qualité et prévention des incidents immuno-hémolytiques en transfusion sanguine.

Direct and indirect measures of the reliability of the transfusion process are described. These measures can be used to assess the improvement of the transfusion process with a view to preventing hemolytic incidents. Quality assurance arrangements required by their use are made clear. The stress is put upon four points: processes must be formalized and standardised; quality audits must become a routine part of the transfusion process; the system of error reporting must be extended to include all failures; anonymity must be insured to improve reporting.

AUDILAB: a knowledge-based quality audit simulator for testing laboratories.

In order to obtain an accreditation, a laboratory must be prepared to provide a point-by-point check of various activities against the chosen reference standard, both from a general point of view and in relation to details of application. This paper describes AUDILAB, a computerized simulator accessible by network, able to provide testing laboratories with realistic quality audits performed in a customized way. AUDILAB establishes a detailed list of strengths (compliance with corresponding requirements of established standards) and weaknesses (improvements needed for laboratory's accreditation). The standard used by AUDILAB is the EN 45001 "General criteria for the operation of testing laboratories". A preliminary validation has already been completed. AUDILAB became operational in September 1993.

The French communicable diseases computer network: a technical view.

This paper describes an information system (IS) established in France in 1984 for the national surveillance of communicable diseases. This IS is based on a videotex server and a relational database management system. The videotex server is the IS front-end. It performs the following functions: interpersonal communications, synthetic information retrieval into an epidemiologic info-base and data entry owing to its specialized applications. The relational database management system allows the user to manage and consult an epidemiologic database updated in quasi-real time. Several specific tools have also been developed in order to enhance data representation and analysis and the decision support capabilities of the IS.

A sequential procedure to test the progressive decrease of rare adverse events.

A program to construct the Rapid Sequential Test (R-ST), a sequential procedure to test the decrease of the rate of rare adverse events, is described. This sequential procedure is constructed with the Sequential Probability Ratio method. It relies on a model for the progressive decrease in the rate of adverse events from a given initial rate to a target rate, during a transition period. The program allows one to calculate the bounds of rejection of the R-ST, and to study its power under various types of decrease. It is shown that the R-ST gives a conclusion faster than standard sequential procedures for the same type I and II error, saving at least one quarter of the trials completed during the transition period. The use of the software to construct R-STs is discussed with respect to the specification of the model.

Outpatient preoperative evaluation clinic can lead to a rapid shift from inpatient to outpatient surgery: a retrospective review of perioperative setting and outcome.

STUDY OBJECTIVE: To report the rapid shift from inpatient to outpatient surgery that occurred after opening an outpatient preoperative evaluation clinic and the perioperative complications and mortality rates before and after this intervention. DESIGN: Monthly variations of total volume of procedures and percentages of outpatient procedures were analyzed retrospectively using control charts over two consecutive 10-month periods before and after the intervention. For each type of procedure (inpatient vs. outpatient), the perioperative complications and 30-day mortality rates were compared between periods. SETTING: The Veterans Affairs Palo Alto Health Care System, Palo Alto, California. PATIENTS: Patients who underwent 3,159 inpatient or outpatient procedures in the main operating room suite during the control period were compared with patients who underwent 3,190 procedures in the same operating room suite during the intervention period. INTERVENTION: The establishment of an outpatient preoperative evaluation clinic. MEASUREMENTS AND MAIN RESULTS: For each period, the total monthly surgical volume (inpatient and outpatient), perioperative complications, deaths within 30 days of surgery, and the number of procedures performed on patients classified as ASA physical status III, IV, or V were analyzed. The monthly total number of procedures was stable over both periods, but the monthly percentage of outpatient procedures departed from its baseline immediately after establishing the clinic (control period: 24.7%; study period: 45.4%; p << 0.0001). Finally, the perioperative complication rate did not change for outpatient procedures but increased for inpatient procedures (control period: 2.31%; study period: 3.50%; p < 0.05). The 30-day mortality rate remained unchanged for inpatient and outpatient procedures. CONCLUSIONS: Establishing an outpatient preoperative evaluation clinic can lead to a rapid shift from inpatient to outpatient surgery at a government funded hospital without a concomitant increase in perioperative morbidity or mortality.

[A discrete-events computer model of fox rabies]. / Un modèle informatique événementiel de la rage vulpine.

A technique of discrete events simulation is used to construct a model of an epi-enzootic disease of vulpine rabies. Because this technique is easy to use, it makes it possible to take into account different spatial and temporal characteristics of the dynamics of vulpine populations and transmission of rabies. Thereby, the model simulates satisfactorily the epi-enzootic disease of rabies presently observed in France.

Quality improvement report: Linking guideline to regular feedback to increase appropriate requests for clinical tests: blood gas analysis in intensive care.

PROBLEM: Need to decrease the number of requests for arterial blood gas analysis and increase their appropriateness to reduce the amount of blood drawn from patients, the time wasted by nurses, and the related cost. DESIGN: Assessment of the impact of a multifaceted intervention aimed at changing requests for arterial blood gas analysis in a before and after study. BACKGROUND AND SETTING: Twenty bed surgical intensive care unit of a tertiary university affiliated hospital, receiving 1500 patients per year. KEY MEASURES FOR IMPROVEMENT: Number of tests per patient day, proportion of tests complying with current guideline, and safety indicators (mortality, incident rate, length of stay). Comparison of three 10 month periods corresponding to baseline, pilot (first version of the guideline), and consolidated (second version of the guideline) periods from March 1997 to August 1999. STRATEGIES FOR CHANGE: Multifaceted intervention combining a new guideline developed by a multidisciplinary group, educational sessions, and monthly feedback about adherence to the guideline and use of blood gas analysis. EFFECTS OF CHANGE: Substantial decrease in the number of tests per patient day (from 8.2 to 4.8; P<0.0001), associated with increased adherence to the guideline (from 53% to 80%, P<0.0001). No significant variation of safety indicators. LESSONS LEARNT: A multifaceted intervention can substantially decrease the number of requests for arterial blood gas analysis and increase their appropriateness without affecting patient safety.

Modelling health care processes with SHARE.

This paper describes the "SHARE" workframe, designed to provide a comprehensive environment for modeling and simulating health care processes. The objects defined within SHARE are Actors, subdivided in Clients and Resources, and Elementary Operations. Graphical tools allow to build processes from these objects, and to specify their relationships. Various strategies based on either clinical or managerial changes may be investigated. Summary information on the utilization of all actors, on waiting times and goodness of execution may be displayed after a simulation. Better description of processes, and their study a priori will improve reliability, quality of care and satisfaction of patients.

Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback.

BACKGROUND: The potential severity of wrong patient/procedure/site of surgery and the view that these events are avoidable, make the prevention of such errors a priority. An intervention was set up to develop a verification protocol for checking patient identity and the site of surgery with periodic audits to measure compliance while providing feedback. ASSESSMENT OF PROBLEM: A nurse auditor performed the compliance audits in inpatients and outpatients during three consecutive 3-month periods and three 1-month follow-up periods; 11 audit criteria were recorded, as well as reasons for not performing a check. STRATEGY FOR CHANGE: The nurse auditor provided feedback to the health professionals, including discussion of inadequate checks. RESULTS: 1,000 interactions between patients and their anaesthetist or nurse anaesthetist were observed. Between the first and second audit periods compliance with all audit criteria except "surgical site marked" noticeably improved, such as the proportion of patients whose identities were checked (62.6% to 81.4%); full compliance with protocol in patient identity checks (9.7% to 38.1%); proportion of site of surgery checks carried out (77.1% to 92.6%); and full compliance with protocol in site of surgery checks (32.2% to 52.0%). Thereafter, compliance was stable for most criteria. The reason for failure to perform checks of patient identity or site of surgery was mostly that the anaesthetist in charge had seen the patient at the preanaesthetic consultation. LESSONS AND MESSAGES: By combining the implementation of a verification protocol with periodic audits with feedback, the intervention changed practice and increased compliance with patient identity and site of surgery checks. The impact of the intervention was limited by communication problems between patients and professionals, and lack of collaboration with surgical services.