[The role of the primary care physician in the evolution of a care model in a medico-educational establishment]. / Rôle du médecin de premier recours dans l'évolution d'un modèle de soins d'une institution médico-éducative.

Following the retirement of the referring physician of an institution for people with intellectual and developmental disabilities (DID), the residents found themselves without a general internist. A joint reflection then took place between four actors concerned by the subject: the management of the institution, the health department, Valais hospital and the family and child physician canton branch. At the end of the project, the primary care physician is found to be central to caseload management. Four areas of work have been defined: computerization of the patient files, the consolidation of an interdisciplinary care network, the adaptation of hospital procedures to patients' disabilities and the implementation of continuing education.

Suite au départ à la retraite du médecin référent des résidents d'une institution pour personnes avec déficience intellectuelle et développementale, les résidents se sont retrouvés sans médecin interniste généraliste. Une réflexion commune fut alors menée par 4 acteurs concernés par le sujet : la direction de l'institution, le département de la santé, l'hôpital du Valais et la branche cantonale de Médecin de famille et de l'enfance. À l'issue du projet, la médecine de premier recours se retrouve au centre des prises en charge. Quatre axes de travail ont été définis : l'informatisation des dossiers patients, la consolidation d'un réseau de soins interdisciplinaires, l'adaptation des procédures hospitalières au handicap des patients et la mise en place d'une formation continue.

[Diagnostic and therapeutic management of medium and long-term sequelae of SARS-CoV-2 infection]. / Prise en charge diagnostique et thérapeutique des séquelles à moyen et long termes liées à l'infection à SARS-CoV-2.

Somatic or psychological sequelae after a SARS-CoV-2 infection are common. Specific organ damage should be investigated to explain persistent symptomatology and propose a treatment. A specialized consultation for the follow-up of patients after a SARS-CoV-2 infection is useful to clinically assess the patient, organized further investigations, offer treatment options and refer the patient to other specialists or to a rehabilitation program. Such a consultation is also intended to reduce the public health burden of long Covid and to collect data that can improve our management in the future.

Les séquelles somatiques ou psychologiques après une infection à SARS-CoV-2 sont fréquentes. Des atteintes d'organes spécifiques doivent être recherchées pour expliquer une symptomatologie persistante et proposer un traitement. Une consultation spécialisée pour le suivi des patients après une infection à SARS-CoV-2 est utile pour évaluer cliniquement le patient, organiser les examens complémentaires, offrir des options de traitements et orienter le patient vers d'autres spécialistes ou un programme de réhabilitation. Une telle consultation a également pour objectif de diminuer le fardeau du Covid long sur la santé publique et de collecter les données qui pourront améliorer notre prise en charge dans le futur.

Comprehensive assessment of critical care needs in a community hospital*.

OBJECTIVE: To design and implement a needs assessment process that identifies gaps in caring for critically ill patients in a community hospital. DESIGN, SETTING, SUBJECTS: This mixed-method study was conducted between June 2011 and February 2012. A conceptual framework, centered on the critically ill patient, guided the design and selection of the data collection instruments. Different perspectives sampled included regional leaders, healthcare professionals at the community hospital and its referral hospital, as well as family members of patients who had received care at the community ICU. Data sources included interviews (n = 22), walk-throughs (n = 5), focus groups (n = 31), database searches, context questionnaires (n = 8), family surveys (n = 16), and simulations (n = 13). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nine needs were identified. At the community hospital, needs identified included lack of access to human resources, gaps in expertise, poor patient flow and ICU bed use, communication, lack of educational opportunities, and gaps in end-of-life care and interprofessional teamwork. Needs were also identified in the interhospital interaction between the community and referral hospitals, which included an inadequate hospital network and gaps in transfer and repatriation of patients. The methodology uncovered the causes and widespread impact of each need and how they interacted with one another. Proposed solutions by the participants are presented including both organizational and educational/clinical solutions. CONCLUSIONS: This study captured needs in a complex, interprofessional, interhospital context, which can be targeted with tailored interventions to improve patient outcomes in a community hospital. Furthermore, this study provides a preliminary framework and rigorous methodology to performing a needs assessment in this setting.

Implementation of clinical practice guidelines for ventilator-associated pneumonia: a multicenter prospective study.

OBJECTIVE: Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates. DESIGN: Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009. SETTING: Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs. PATIENTS: At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months). INTERVENTION: Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p < .001), as did aggregate concordance (mean [SD]): 50.7% (6.1), 54.4% (7.1), 56.2% (5.9), 58.7% (6.7) (p = .007). Over the study period, ventilator-associated pneumonia rates decreased (events/330 patients): 47 (14.2%), 34 (10.3%), 38 (11.5%), 29 (8.8%) (p = .03). CONCLUSIONS: A 2-yr multifaceted intervention to enhance ventilator-associated pneumonia guideline uptake was associated with a significant increase in guideline concordance and a reduction in ventilator-associated pneumonia rates.

Multi-professional recommendations for access and utilization of critical care services: towards consistency in practice and ethical decision-making processes.

Multiprofessional guidelines for fair access to and use of adult critical care services are desperately needed to define a consistent transparent standard of care: when such therapies have the potential to benefit and help a patient as they journey with illness and when they cannot.

Training of medical and paramedical personnel in burn care and prevention.

This paper discusses the requirements for training in burn care within a resource limited environment, what is currently practiced and goes on to suggest a strategy for effective delivery of education and training.

Single rooms may help to prevent nosocomial bloodstream infection and cross-transmission of methicillin-resistant Staphylococcus aureus in intensive care units.

OBJECTIVE: Nosocomial infections remain a major problem in intensive care units. Several authorities have recommended housing patients in single rooms to prevent cross-transmission of potential pathogens, but this issue is currently debated. The aim of the present study was to compare the rate of nosocomial cross-contamination between patients hosted in single rooms versus bay rooms. DESIGN: Prospective observational data acquisition over 2.5 years. SETTING: A 14-bed medico-surgical ICU, composed of six single-bed rooms plus a six-bed and a two-bed bay room served by the same staff. PATIENTS AND PARTICIPANTS: All patients admitted from 1 July 2002 to 31 December 2004. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in admitted patients was 1.1% and acquisition rate 2.4%. The incidence density of MRSA acquisition was 4.1 [95% CI 2.7-6.3]/1,000 patient-days in bay rooms versus 1.3 [0.5-3.4]/1,000 patient-days in single rooms (p<0.001). Pseudomonas spp. acquisition rate was 3.9 [2.5-6.1]/1,000 patient-days in bay rooms versus 0.7 [0.2-2.4]/1,000 patient-days in single rooms (p<0.001), and Candida spp. colonization was 38.4 [33.3-44.1]/1,000 patient-days in bay rooms versus 13.8 [10.2-18.6]/1,000 patient-days (p<0.001). By multivariate analysis, the relative risk of MRSA, Pseudomonas aeruginosa and Candida spp. acquisition in single rooms or cubicles versus bay rooms was 0.65, 0.61 and 0.75 respectively. CONCLUSIONS: These data suggest that in an institution where MRSA is not hyperendemic, infection control measures may be more effective to prevent cross-transmission of microorganisms in patients housed in single rooms.