Carriage of multidrug-resistant Gram-negative bacilli: duration and risk factors.

Identification of risk factors influencing the duration of carriage of multidrug-resistant Gram-negative bacilli (MDR-GNB) may be useful for infection control. The aim of this study is to estimate the impact of several factors collected for routine hospital surveillance on the duration of carriage of selected MDR-GNB. From January 2015 to July 2021, patients with at least two clinical/surveillance samples positive for MDR-GNB different from ESBL-producing E. coli or AmpC - exclusively producing Enterobacterales were assessed. Microorganisms, age, number of admissions, clinical or rectal sample, sex, and admission service were evaluated as risk factors. Multivariate analysis was performed by a Cox proportional hazard model. A total of 1981 episodes of colonization were included. Involved microorganisms were ESBL-Klebsiella pneumoniae (KP) in 1057 cases (53.4%), other ESBL-non-E. coli Enterobacterales in 91 (4.6%), OXA-48-KP in 263 (13.3%), KPC-KP in 90 (4.5%), VIM-KP in 29 (1.5%), carbapenemase-producing non-KP Enterobacterales (CP-non-KP) in 124 (6.3%), and MDR Pseudomonas aeruginosa (MDR-PAER) in 327 (16.5%). No differences in duration of colonization were observed among ESBL-KP (median colonization time 320 days), ESBL-non-E. coli Enterobacterales (226 days), OXA48-KP (305 days), and MDR-PAER (321 days). For each group, duration of colonization was significantly longer than that of KPC-KP (median colonization time 60 days), VIM-KP (138 days), and CP-non-KP (71 days). Male sex (HR = 0.88; 95% CI 0.78-0.99), detection in Hepatology-Gastroenterology (HR = 0.71; 95% CI 0.54-0.93), clinical sample (HR = 0.61; 95% CI 0.53-0.69), and > 2 admissions after first detection (HR = 0.47; 95% CI 0.42-0.52) were independent predictors of longer carriage, whereas VIM-KP (HR = 1.61; 95% CI 1.04-2.48), KPC-KP (HR = 1.85; 95% CI 1.49-2.3), and CP-non-KP (HR = 1.92; 95% CI 1.49-2.47) were associated with shorter colonization time. Duration of colonization was significantly longer for ESBL-KP, other ESBL-non-E. coli Enterobacterales, OXA-48-KP, and MDR-PAER. For these microorganisms, prolonging surveillance up to 2.5-3 years should be considered. Male sex, clinical sample, multiple readmissions, admission service, and type of microorganism are independent predictors of the duration of carriage.

Methodological guidelines for preparing a structured therapeutic education program: From design to evaluation. / Guía metodológica para la elaboración de un programa estructurado de educación terapéutica: del diseño a la evaluación.

BACKGROUND AND OBJECTIVE: Therapeutic patient education (TPE) is effective and essential in the context of the growing prevalence of chronic diseases, in which tools are needed for planning structured programs. The objective of this project was to develop guidelines for designing and assessing a TPE program. METHODS: 1) We assembled a multidisciplinary group of 8 leaders in TPE, chronicity, quality and safety from the hospital and the university. 2) We conducted an exhaustive review of the scientific literature on the planning of TPE programs directed at chronically ill patients, their relatives and caregivers. 3) The final text underwent comments and suggestions by participants from the hospital and primary care centre during a course on information and TPE methodology. The recommendations were unanimously agreed upon by the writing group. RESULTS: We obtained a standardised work procedure targeted at professionals involved in planning TPE programs, based on international recommendations. The document is structured into sections: a) Definition of the health problem and analysis of the situation; b) Program structure (human resources and materials); objectives (health-related, behaviour-related and educational) and methodology; c) Path the patient and family/caregiver follows in the program; and d) Assessment and indicators. The assessment of the procedure, in the framework of the methodology courses, was favourable. CONCLUSIONS: The methodology provided by this document serves as an instrument for the standardised and systematic planning of educational programs and unifies the criteria in their drafting. However, the document needs to be adapted to the condition and population to which each program is directed.

A hospital incident reporting system (2016-2019): Learning from notifier's perception on incidents' risk, severity and frequency of adverse events.

Incident reporting systems (IRSs) are considered safety culture promoters. Nevertheless, they have not been contemplated to monitor professionals' perception about patient safety related risks. This study aims to describe the characteristics and evolution of incident notifications reported between 2016 and 2019 in a high complexity reference hospital in Barcelona and explores the association between notifications' characteristics and notifier's perception about incidents severity, probability of occurrence and risk. The main analysis unit was notifications reported. A descriptive analysis was performed and taxes by hospital activity were calculated. Odds ratios were obtained to study the association between the type of incident, the moment of incident, notifiers' professional category, reported incident's severity, probability and incidents' calculated risk. Through the study period, a total of 6379 notifications were reported, observing an annual increase of notifications until 2018. Falls (21.22%), Medical and procedures management (18.91%) and Medication incidents (15.49%) were the most frequently notified. Departments reporting the highest number of notifications were Emergency room and Obstetrics & Gynaecology. Incident type and notifiers' characteristics were consistently included in the models constructed to assess risk perception. Pharmaceutics were the most frequent notifiers when considering the proportion of staff members. Notification patterns can inform professionals' patient risk perception and increase awareness of professionals' misconceptions regarding patient safety.

Analysis of the quality of patient therapeutic education and information in a high complexity reference hospital.

BACKGROUND AND OBJECTIVES: The application and monitoring of quality criteria in information and therapeutic patient education can identify areas to improve care. The objectives of this study were: (1) To analyze the characteristics of patient information materials, educational activities, and self-management programs, and (2) to determine health care provider (HCP) proposals on therapeutic patient education. MATERIALS AND METHODS: Using a cross-sectional study, an online questionnaire was sent to hospital departments in a high complexity reference hospital from September to December 2013 to record: (a) information materials, (b) patient educational activities, and self-management program characteristics, (c) HCP proposals. The materials were analyzed using Health Promoting Hospitals (HPH) recommendations. RESULTS: (1) An analysis was performed on 258 materials (leaflets [54%]) for chronic patients (86%), acute patients (7%), and the general population (7%). More than half (55%) lacked the authors, and 43% the year issued, and 69% followed HPH recommendations. (2) An evaluation was made of 70 educational activities and 37 self-management programs addressed to patients/relatives with diabetes/obesity, musculoskeletal disorders, COPD/asthma, pelvic-floor disorders, transplantation, bowel-inflammation/liver disease, hypertension, cancer, heart failure, acquired immune deficiency syndrome, chronic renal insufficiency, splenectomy, anticoagulation and older-patient dependence. The structure, process and outcome evaluation varied. (3) HCP proposals included: standardization of materials criteria, web accessibility, list of accredited websites, cross-sectional use, and HCP training in self-management education. CONCLUSIONS: The online questionnaire showed the weaknesses and strengths of patient information and education, and can be used to monitor their quantity and quality. These results help in the definition of a useful model to improve patient information and education policies.

Spanish and Catalan translation, cultural adaptation and validation of the Picker Patient Experience Questionnaire-15.

OBJECTIVE: To develop and test a culturally adapted core set of questions to measure patients' experience after in-patient care. MATERIAL AND METHODS: Following the methodology recommended by international guides, a basic set of patient experience questions, selected from Picker Institute Europe questionnaires (originally in English), was translated to Spanish and Catalan. Acceptability, construct validity and reliability of the adapted questionnaire were assessed via a cross-sectional validation study. The inclusion criteria were patients aged >18 years, discharged within one week to one month prior to questionnaire sending and whose email was available. Day cases, emergency department patients and deaths were excluded. Invitations were sent by email (N=876) and questionnaire was fulfilled through an online platform. An automatic reminder was sent 5 days later to non-respondents. RESULTS: A questionnaire, in Spanish and Catalan, with adequate conceptual and linguistic equivalence was obtained. Response rate was 44.4% (389 responses). The correlation matrix was factorable. Four factors were extracted with Parallel Analysis, which explained 43% of the total variance. First factor: information and communication received during discharge. Second factor: low sensitivity attitudes of professionals. Third factor: assessment of communication of medical and nursing staff. Fourth factor: global items. The value of the Cronbach alpha was 0.84, showing a high internal consistency. CONCLUSIONS: The obtained experience patient questionnaire, in Spanish and Catalan, shows good results in the psychometric properties evaluated and could be a useful tool to identify opportunities for health care improvement in our context. Email could become a feasible tool for greater patient participation in everything that concerns his health.

[Quality standards of educational activities for patients and families in a university hospital]. / Estándares de calidad de actividades educativas dirigidas a pacientes y familiares en un hospital universitario.

OBJECTIVE: To identify groups of patients receiving hospital-based educational programs, to determine whether the education was structured or ad hoc, and to analyse information on the structure, process and results of the programs. MATERIAL AND METHODS: We performed a cross-sectional study using a translated and adapted version of the National Standards for Diabetes Self-Management Education. Information was collected on structure (resources, availability of a written program and professional training), the process followed by the patient (baseline assessment, methodology, training courses, support materials and record of activities), patient outcomes (post-intervention assessment, tools, record of evaluation and results) and program results (number of patients/relatives included, regular assessment). RESULTS: Patient groups receiving education were: patients with chronic diseases, patients with treatable psychiatric disorders and patients with oncological and haematological processes. Most educational activities involved informative activities and technical skills training, both on-demand and integrated in care activity. Structured therapeutic education programs were aimed at patients/relatives with: diabetes, obesity, musculoskeletal diseases, AIDS, splenectomy, chronic obstructive pulmonary disease, hypertension and urinary incontinence. Not all programs had written guidelines or defined parameters with respect to structure, process and results. CONCLUSIONS: The application of quality standards to hospital educational programs is useful in detecting: patients receiving education and the quality, type and weaknesses of the programs studied. Software based on these standards may provide information on trends in patient education, identify opportunities for improvement and aid the evaluation of the impact of each educational activity on the quality indicators associated with each program.

The burden of chronic disorders on hospital admissions prompts the need for new modalities of care: a cross-sectional analysis in a tertiary hospital.

BACKGROUND: Chronic disorders constitute a primary concern because of their burden on healthcare systems worldwide. Integrated care strategies enhancing the interface between tertiary care and primary care are pivotal to improve chronic care. AIM: To asses the prevalence of chronic disorders on hospital discharges and their impact on unplanned admissions and mortality. DESIGN: Cross-sectional analysis of discharge information over 1 year (2004) in one University hospital. METHODS: Adoption of an operational definition of chronic disorder based on the WHO. MAIN OUTCOME: co-morbid conditions, emergency room and hospital admissions, outpatient consultations and mortality. RESULTS: Fifty-eight percent of patients presented at least one chronic condition (19 192 patients, 53% males, 63 +/- 18 years) as primary (12 526 patients, 38%) or secondary diagnosis. The Charlson index was 2 +/- 3. Each chronic condition was associated with a 30% increase of having had an admission in the previous year. Up to 9% (1 656) of chronic patients showed multiple admissions in the previous year: two (917 patients, 55%), three (360, 22%) and four or beyond (379, 23%), being mostly unscheduled hospitalizations. The three most prevalent chronic disorders were cancer, cardiovascular diseases and chronic obstructive pulmonary disease (COPD). The rate of admissions was associated with co-morbidity (P < 0.001) and mortality (P < 0.001). CONCLUSION: The study shows a high impact of cancer on planned hospitalizations whereas cardiovascular diseases and COPD generates a high percentage of unscheduled admissions. We conclude that integrated care services including patient-oriented guidelines are strongly needed to enhance both health and managerial outcomes.

[Analysis of the cost-effectiveness relationship in the empirical treatment in patients with infections of the lower respiratory tract acquired in the community]. / Análisis de la relación coste-efectividad del tratamiento antibiótico empírico en pacientes con infecciones del tracto respiratorio inferior adquiridas en la comunidad.

BACKGROUND: Cost of treatment of community-acquired infections in Spain is an important factor in overall health expenditures. The aim of this study was to assess the direct health costs related with the treatment of patients with community-acquired pneumonia (CAP) and acute exacerbations of chronic bronchitis (AECB) due to infection, using different antibiotic options, and to identify main cost drivers. METHODS: A basic decision analysis model was developed, including probabilities estimation derived from the literature review, supplemented when needed by the opinion of a panel of 8 Spanish physicians (Delphi technique). Four groups of antibiotics were included (macrolides, beta-lactam, fluoroquinolones and cephalosporins) in two different groups: patients with CAP without hospital admission criteria and patients with AECB due to respiratory infection. The analytic horizon and the perspective used were those of the Spanish National Health Service. Direct cost were assessed (drugs, outpatient visits, hospital admissions, diagnostic tests). Indirect cost were not included in the model. Final costs uses as main outcome measure the average cost per patient treated. All results were calculated following a fold-back technique. Sensitivity analysis were included allowing for variations in several clinically relevant parameters. RESULTS: 1. Patients with CAP: Hospital admissions, directly related to the effectiveness rate of initial empirical antibiotic therapy, were the main cost driver (50%-70%). Acquisition costs of initial antibiotic therapy only account for 2%-13% of total costs. 2. Patients with AECB: Outpatient visits are the main cost driver for these group of patients (49% of total costs). Hospital admission costs are also an important cost driver (40%-51% of total costs). Acquisition costs of initial antibiotic therapy account for 4%-28% of total costs. Clinical effectiveness of first antibiotic option is the main variable regarding the cost-effectiveness rate. CONCLUSION: The model here presented showed that acquisition costs of first empirical antibiotic therapy are only a small proportion of total costs related with the management of community acquired lower respiratory tract infections in Spain. The clinical effectiveness rate of the first antibiotic used is the main variable which determines the final average cost per patient cured. For patients with lower respiratory tract infections the therapeutic option with a better cost-effectiveness ratio must be chosen, in order to minimize the risk of therapeutic failure after first line therapy, and should not be selected only by its lower acquisition costs.

Prevalence of hepatitis B infection in long-stay mentally handicapped adults.

The objective was to determine the prevalence of hepatitis B virus (HBV) infection in long-stay institutionalized mentally handicapped adults and to develop a vaccination programme for them. The study was carried out in 1994. The subjects were 171 mentally handicapped adults aged 37-76 (median age 56) with a median hospital stay of 30 years (range 6-47). Markers for infection were determined using ELISA. Seronegative patients were vaccinated using the standard schedule, and the titre of antiHBs reached was determined later. The prevalence of seropositive subjects was 81.3%. Seropositive subjects had a longer hospital stay (median stay of 32 years, range: 15-47) than seronegative ones (median stay of 15 years, range: 6-33). A total of 43.3% of the vaccinated subjects developed antiHBs antibodies (GMT: 135 IU/l). The high prevalence of HBV exposure is probably a legacy of a past era which is reflected in patients with prolonged institutionalisation in a closed regime. The need for immediate vaccination of mentally handicapped subjects is of the utmost importance, as it has been shown that the response to the vaccine worsens with age.

Immunogenicity and reactogenicity of the adult tetanus-diphtheria vaccine. How many doses are necessary?

The immunogenicity and reactogenicity of the tetanus-diphtheria adult type vaccine was compared in two groups: group I (n = 201, 18-30 years old, presumably vaccinated with the DTP vaccine) and group II (n = 147, > or = 45 years old, without vaccination antecedents). Before vaccination, the seroprotection levels for tetanus were 90.5% (group I) and 30.6% (group II). These rose to 99.5% and 81.7%, respectively, after administration of one vaccine dose. For diphtheria, prevaccination seroprotection levels were 38.3% (group I) and 19.0% (group II). These rose to 85.8% and 65.7%, respectively, after vaccination. The logistic regression analysis showed an association between antibody titre and age. In group II, 3 doses of Td vaccine were needed to reach titres similar to those achieved in group I with a single dose. Stated reactogenicity was greater in: young subjects, women, those with higher titres of tetanus antibodies and those receiving other vaccines simultaneously. These results confirm the need for vaccination schedules adapted to the characteristics of each population age-group.

Cost analysis of two strategies for preventing hepatitis A virus infection in Spanish travellers to developing countries.

Our objectives were to assess the prevalence of anti-hepatitis A (HAV) antibodies in Spanish travellers to developing countries and to carry out a cost analysis to allow the comparison of two vaccination strategies. Adult subjects were selected from among travellers to developing countries. Information was obtained on age, sex, destination, previous vaccination against HAV and having received immunoglobulin. Blood specimens were obtained for anti-HAV antibody determination. A total of 485 travellers were studied. The prevalence of anti-HAV antibody was 30.5% (95% CI 26-35). Antibody prevalence was inversely correlated with age: 9.8% in 18-25 years of age, rising to 75.4% in those 41-55 years of age. Cost analysis determined that the critical value of prevalence for vaccination with HAV vaccine was 37.5%. It was concluded that the youngest Spanish travellers lack anti-HAV antibodies. Vaccination without screening in those < or = 35 years of age and screening before vaccination for those > 35 years, are the preferred alternatives.