[Systematic identification of smokers and tobacco smoking management in the general hospital]. / Repérage systématique et prise en charge du tabagisme à l'hôpital général.

INTRODUCTION: The prevalence of daily smoking in France was 24 % in 2019 and tobacco control remains a major public health issue. A hospital stay provides an opportunity for smoking cessation intervention. Identification and management of smokers during a hospital stay may be variously integrated into electronic health records (EHR). STATE OF THE ART: Smoking status identification, which have included pre-filled forms, check-box, reminders, icons, is heterogeneous. Specific modules in EHR have been implemented for smoking cessation management such as counselling sessions, tobacco cessation prescriptions, smoking cessation guidelines and long-term follow-up. EHR-based intervention to identify and manage smokers with a long-term follow-up for at least one month after hospital discharge has shown an increase in smoking abstinence at 6-12 months. OUTLOOK: Due to the lower quality of free data about smoking status, systematic identification with check-box, reminders or icons in EHR may be more appropriate. Integration of functionalities such as help for prescription, reminders and follow-up of patients would make tobacco cessation management easier for health professionals. CONCLUSION: EHR interventions to identify smokers and manage smoking cessation during hospital stays are an opportunity to increase smoking cessation.

Colorectal stenting in England: a cross-sectional study of practice.

INTRODUCTION: UK and European guidelines recommend consideration of a self-expandable metallic stent (SEMS) as an alternative to emergency surgery in left-sided colonic obstruction. However, there is no clear consensus on stenting owing to concern for complications and long-term outcomes. Our study is the first to explore SEMS provision across England. METHODS: All colorectal surgery department leads in England were contacted in 2018 and invited to complete an objective multiple choice questionnaire pertaining to service provision of colorectal stenting (including referrals, time, location and specialty). RESULTS: Of 182 hospitals contacted, 79 responded (24 teaching hospitals, 55 district general hospitals). All hospitals considered stenting, with 92% performing stenting and the remainder referring. The majority (93%) performed fewer than four stenting procedures per month. Most (96%) stented during normal weekday hours, with only 25% stenting out of hours and 23% at weekends. Compared with district general hospitals, a higher proportion of teaching hospitals stented out of hours and at weekends. Stenting was performed in the radiology department (64%), the endoscopy department (44%) and operating theatres (15%), by surgeons (63%), radiologists (60%) and gastroenterologists (48%). A radiologist was present in 66% of cases. Of 14 hospitals that received referrals, 3 had a protocol, 3 returned patients the same day and 4 returned patients for management in the event of failure. CONCLUSIONS: All responding hospitals in England consider the use of SEMS in colonic obstruction. Nevertheless, there is great variation in stenting practices, and challenges in terms of access and expertise. Centralisation and regional referral networks may help maximise availability and expertise but more work is needed to support this.

"Somebody else's business": The challenge of caring for patients with mental health problems on medical and surgical wards.

WHAT IS KNOWN ON THE SUBJECT?: People with mental health problems have higher rates of physical health concerns and hospital admissions than those without mental health problems. These patients have poorer outcomes from surgery and have worse experiences of care when admitted for medical or surgical procedures. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper looks to understand why care may be poorer for patients with mental health problems by speaking to staff providing care in these settings. We spoke to 30 general hospital staff about mental health on the wards and found that a lack of leadership and ownership for prioritising mental health led to people not seeing it as their job, and that it was somebody else's business to manage that side of care. We also found that the emotional effect of caring for people who had attempted suicide or had self-harm injuries was difficult for staff, impacting on staff well-being and leading them to distance themselves from providing care in those cases. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is a need for staff to be supported from the top-down, with management providing clear leadership around issues and pathways for mental health needs so they know the best way to provide care and encourage collaborative working. In addition, bottom-up support is needed to help staff personally manage their own well-being and mental health, including supervision and debriefing from mental health specialists to improve understanding from the patient's perspective and to provide emotional support to manage difficulties. RELEVANCE STATEMENT: This paper places focus on the care of patients with mental health problems in medical and surgical care settings highlighting the interplay between mental and physical health from a perspective that is less often explored. This paper provides insights into the multidisciplinary nature of nursing and the need for integrated care. This provides findings that build a picture of how mental health nursing specialism is needed beyond psychiatric wards and within medical and surgical settings. ABSTRACT: Introduction Evidence shows that patients with mental health problems have poorer physical health outcomes, increased mortality and experience poorer care during surgery and medical admissions. Issues related to lack of training, stigmatizing attitudes, fear or hopelessness may help understand these poor outcomes. Aim To explore the experiences of staff in providing care for people with mental health problems. Method A qualitative service evaluation approach was used. Participants working in an acute care hospital in inner-city London were recruited across professions and job levels using a self-selection sampling method. A total of 30 participants took part in semi-structured interviews (n = 17) and two focus groups (n = 13), and data were thematically analysed. Relevant organizational documents and service use data were utilized to inform the evaluation. Results Key themes were organized across the macro, meso and micro levels to understand the levels of disconnection and silence around mental health in acute care. Themes include systemic factors surrounding the institutional culture, ward cultures and collaborative working, and individuals' sense-making of mental health and personal well-being. Implications for practice These findings signpost the growing need for greater mental health nursing input on medical and surgical wards and within these teams to provide informed knowledge, support and supervision.

Top-tier emergency general surgery hospitals: Good at one operation, good at them all.

BACKGROUND: There is a longstanding interest in the field of management science to study high performance organizations. Applied to medicine, research on hospital performance indicates that some hospitals are high performing, while others are not. The objective of this study was to identify a cluster of high-performing emergency general surgery (EGS) hospitals and assess whether high performance at one EGS operation was associated with high performance on all EGS operations. METHODS: Adult patients who underwent one of eight EGS operations were identified in the California State Inpatient Database (2010-2011), which we linked to the American Hospital Association database. Beta regression was used to estimate a hospital's risk-adjusted mortality, accounting for patient- and hospital-level factors. Centroid cluster analysis grouped hospitals by patterns of mortality rates across the eight EGS operations using z scores. Multinomial logistic regression compared hospital characteristics by cluster. RESULTS: A total of 220 acute care hospitals were included. Three distinct clusters of hospitals were defined based on assessment of mortality for each operation type: high-performing hospitals (n = 66), average performing (n = 99), and low performing (n = 55). The mortality by individual operation type at the high-performing cluster was consistently at least 1.5 standard deviations better than the low-performing cluster (p < 0.001). Within-cluster variation was minimal at high-performing hospitals compared with wide variation at low-performing hospitals. A hospital's high performance in one EGS operation type predicted high performance on all EGS operation types. CONCLUSION: High-performing EGS hospitals attain excellence across all types of EGS operations, with minimal variability in mortality. Poor-performing hospitals are persistently below average, even for low-risk operations. These findings suggest that top-performing EGS hospitals are highly reliable, with systems of care in place to achieve consistently superior results. Further investigation and collaboration are needed to identify the factors associated with high performance. LEVEL OF EVIDENCE: Prognostic, level III.

Crohn's & Colitis Australia inflammatory bowel disease audit: measuring the quality of care in Australia.

BACKGROUND: Australia has among the highest prevalence of Crohn disease and ulcerative colitis in the world. Management of the chronic gastrointestinal disorders results in significant societal costs and the standard of care is inconsistent across Australia. AIM: To audit the quality of care received by patients admitted for inflammatory bowel disease (IBD) across Australia against national IBD standards. METHODS: A retrospective cross-sectional survey and clinical audit was undertaken assessing organisational resources, clinical processes and outcome measures. This study was conducted in Australian hospitals that care for inpatients with Crohn disease or ulcerative colitis. The main outcome measures were adherence to national IBD standards and comparison of quality of care between hospitals with and without multidisciplinary IBD services. RESULTS: A total of 71 hospitals completed the organisational survey. Only one hospital had a complete multidisciplinary IBD service and 17 had a partial IBD service (IBD nurse, helpline and clinical lead). A total of 1440 inpatient records was reviewed from 52 hospitals (mean age 37 years; 51% female, 53% Crohn disease), approximately 26% of IBD inpatient episodes over a 12-month period in Australia. These patients were chronically unwell with high rates of anaemia (30%) and frequent readmissions (40% within 2 years). In general, care was inconsistent, and documentation was poor. Hospitals with a partial IBD service performed better in many processes and outcome measures: for example, 22% reduction in admissions through emergency departments and greater adherence to standards for safety monitoring of biological (89% vs 59%) and immunosuppressive drugs (79% vs 55%) in those hospitals than those without. CONCLUSION: Patients admitted to hospital suffering from IBD are young, chronically unwell and are subject to substantial variations in clinical documentation and quality of care. Only one hospital met accepted standards for multidisciplinary care; hospitals with even a minimal IBD service provided improved care.

Núcleo de segurança do paciente: o caminho das pedras em um hospital geral / Núcleo de seguridad del paciente: el camino de los obstáculos en un hospital general / Patient safety nucleus: the pathway in a general hospital

Resumo OBJETIVO Descrever a experiência da implantação do núcleo de segurança do paciente e as estratégias desenvolvidas para garantir uma assistência mais segura. MÉTODO Relato de experiência da implantação do núcleo e das estratégias para segurança do paciente em um hospital no sul do Brasil, de 2009 a 2017. RESULTADOS A preocupação com a segurança do paciente foi oficializada em 2009 com a criação um serviço específico para gerenciamento dos riscos assistenciais e em 2015 foi nomeado o núcleo de segurança do paciente. Oito estratégias foram implantadas visando disseminar a política de segurança do paciente. CONCLUSÃO Foi observado um avanço na melhoria dos processos relacionados a segurança do paciente na instituição. Apoio da alta direção e engajamento das lideranças foram fundamentais nesta caminhada.

Resumen OBJETIVO Describir la experiencia de la implantación del núcleo de seguridad del paciente y las estrategias desarrolladas para garantizar una asistencia más segura. MÉTODO Relato de experiencia de la implantación del núcleo y de las estrategias para la seguridad del paciente en un hospital en el sur de Brasil, en el período de 2009 a 2017. RESULTADOS La preocupación por la seguridad del paciente fue oficializada en 2009 con la creación de un servicio específico para la gestión de los riesgos asistenciales, y en 2015 se nombró el núcleo de seguridad del paciente. Se implantaron ocho estrategias para diseminar la política de seguridad del paciente. CONCLUSIÓN Se observó un avance en la mejora de los procesos relacionados con la seguridad del paciente en la institución. El apoyo de la alta dirección y el compromiso de los líderes fueron fundamentales en este trayecto.

Abstract OBJECTIVE To describe the experience of implementing the patient safety nucleus and the strategies developed to ensure safer care. METHOD Experience report on the implementation of the nucleus and strategies for patient safety in a hospital in the south of Brazil, from 2009 to 2017. RESULTS The concern with patient safety was made official in 2009 with the creation of a specific service for risk management and in 2015 it was named the patient safety nucleus. Eight strategies were implemented in order to disseminate the patient safety policy. CONCLUSION An improvement was observed in the processes related to patient safety in the institution. Top management support and leadership engagement were key to this journey.

Centro de material e esterilização: reconfiguração da assistência indireta de enfermagem em um hospital geral (2002 a 2007) / Material and sterilization center: reconfiguration of indirect nursing care in a general hospital

O serviço de esterilização de materiais hospitalares no Brasil foi realizado historicamente no mesmo espaço social do centro cirúrgico. Porém, os avanços tecnológicos dos instrumentais e a crescente complexidade dos procedimentos cirúrgicos implicaram na evolução das técnicas de esterilização dos materiais, o que culminou na centralização do Centro de Material e Esterilização (CME) e na concomitante reconfiguração da assistência indireta de enfermagem. Esta pesquisa tem como objeto de estudo a reconfiguração da assistência indireta de enfermagem durante a centralização do setor de esterilização no Hospital Santa Teresa (HST), um hospital geral da rede privada do município de Petrópolis, Região Serrana do Estado do Rio de Janeiro. Objetivos: descrever as circunstâncias que determinaram a centralização do CME no HST; analisar as estratégias empreendidas pela equipe de enfermagem que participou da centralização do CME para a reconfiguração da assistência indireta de enfermagem; Discutir os ganhos simbólicos com a centralização do CME para a assistência indireta da enfermagem, para o HST e para a sociedade. Metodologia: estudo histórico-social, de abordagem qualitativa, na perspectiva da História do Tempo Presente. As fontes históricas foram: primárias escritas: atas de reunião, Procedimento Operacional Padrão (POP) e material de treinamento da equipe de enfermagem; primárias orais: depoimentos temáticos com a participação de oito profissionais; secundárias: livros, dissertações, teses e artigos científicos. Os resultados desse estudo evidenciaram que, antes da centralização do CME, os profissionais de enfermagem dividiam suas práticas entre os cuidados diretos e indiretos no setor de esterilização conjugado ao centro cirúrgico, evidenciando a não exclusividade, sobrecarga de trabalho e prevalência dos cuidados diretos sobre os indiretos. Havia pouca valorização/visibilidade do serviço de esterilização, o qual era considerado desqualificatório para os profissionais que o exerciam. Não havia rotina para dimensionamento de pessoal e eram realizadas práticas que comprometiam o controle efetivo de infecção hospitalar. A partir do cumpra-se legislativo que determinava a centralização do serviço de esterilização, teve início o processo de centralização do serviço de esterilização, que passou a contar com rotinas previstas para o CME a ser centralizado, redimensionamento de pessoal com escalas e a reconfiguração da assistência indireta, que se tornou exclusiva, mais sistematizada e com mais controle sobre os processos de trabalho. Novos profissionais foram contratados para atuar na esterilização e os envolvidos passaram a adquirir novos capitais científicos por meio de educação continuada especialização, treinamento, educação permanente e/ou capacitação. Novas tecnologias foram agregadas ao serviço, inclusive após a efetiva centralização do CME. Conclui-se que as estratégias adotadas pela equipe de enfermagem para reconfigurar a assistência indireta resultaram em ganhos simbólicos para a enfermagem com redução do estresse laboral, maior satisfação no trabalho, autonomia, reconhecimento e valorização profissional; para o HST, que passou a dispor de maior eficácia no controle de infecções hospitalares e gestão financeira relacionada aos insumos mais eficiente; e para a sociedade, que se beneficiou com serviços mais qualificados e seguros prestados pelo hospital.

The hospital materials sterilization service in Brazil was carried out historically in the same social space of the surgical center. However, the technological advances of the instruments and the increasing complexity of the surgical procedures implied in the evolution of the techniques of material sterilization, which culminated in the centralization of the Central Sterile Services Department (CSSD) and the concomitant reconfiguration of the indirect nursing care. This study object is the reconfiguration of indirect nursing care during the centralization of the sterilization sector in Hospital Santa Teresa (HST), a private general hospital of the municipality of Petrópolis, Mountain Region of the State of Rio de Janeiro. Objectives: to describe the circumstances that led to the centralization of the CSSD in HST; to analyze the strategies implemented by the nursing team that participated in the centralization of the CSSD for the reconfiguration of the indirect nursing care; discuss the symbolic gains with the centralization of the CSSD for the indirect assistance of nursing, the HST and the society. Methodology: historical-social study, qualitative approach, from the perspective of the History of Present Time. The historical sources were: written primaries: meeting minutes, Standard Operating Procedure (SOP) and training material of the nursing team; oral primary: thematic statements with the participation of eight professionals; books, dissertations, thesis and scientific articles. The results of this study showed that, prior to the centralization of CSSD, nursing professionals divided their practices between direct and indirect care in the sterilization sector combined with the surgical center, evidencing non-exclusivity, work overload and prevalence of direct care over the indirect. There was little appreciation / visibility of the sterilization service, which was considered disqualifying for the professionals who carried it out. There was no routine for staff sizing and practices performed undermined the effective control of hospital infection. From the legislative resolution that established the centralization of the sterilization service, the process of centralization of this sector began, with routines planned for the CSSD, staff rescaling with scales and the reconfiguration of the indirect assistance, which has become exclusive, more systematized and with more control over work processes. New professionals were hired to perform sterilization, and those involved began to acquire new scientific capital through specialization, training, permanent education and / or training. New technologies were added to the service, even after the effective centralization of the CME. It was concluded that the strategies adopted by the nursing team to reconfigure indirect care resulted in symbolic gains for nursing with reduction of work stress, greater job satisfaction, autonomy, recognition and professional valorization; for HST, which has become more effective in the control of hospital infections and more efficient in financial management of inputs; and to society, which has benefited from more qualified and safe services provided by the hospital.

Patient safety: understanding human error in intensive nursing care.

OBJECTIVE: To analyze the active failures and the latent conditions related to errors in intensive nursing care and to discuss the reactive and proactive measures mentioned by the nursing team. METHOD: Qualitative, descriptive, exploratory study conducted at the Intensive Care Unit of a general hospital. Data were collected through interviews, participant observation and submitted to lexical analysis in the ALCESTE® software and to ethnographic analysis. RESULTS: 36 professionals of the nursing team participated in the study. The analysis originated three lexical classes: Error in intensive care nursing; Active failures and latent conditions related to errors in the intensive care nursing team; Reactive and proactive measures adopted by the nursing team regarding errors in intensive care. CONCLUSION: Reactive and proactive measures influenced the safety culture, in particular, the recognition of errors by professionals, contributing to their prevention, safety and quality care.

Preoperative clinical pathway of breast cancer patients: determinants of compliance with EUSOMA quality indicators.

BACKGROUND: The European Society of Breast Cancer Specialists (EUSOMA) has defined quality indicators for breast cancer (BC). The aim of this study was to describe the preoperative clinical pathway of breast cancer patients and evaluate the determinants of compliance with EUSOMA quality indicators in the Optisoins01 cohort. METHODS: Optisoins01 is a prospective, multicentric study. Data from operable BC patients were collected, including results from before surgery to 1 year follow-up. Seven preoperative EUSOMA quality indicators were compared with the clinical pathways Optisoins01. RESULTS: Six hundred and four patients were included. European Society of Breast Cancer Specialists targets were reached for indicator 1 (completeness of clinical and imaging diagnostic work-up), 3 (preoperative definitive diagnosis) and 5 (waiting time). For indicator 8 (multidisciplinary discussion), the minimum standard of 90% of the patients was reached only in general hospitals and comprehensive cancer centres. Having more than 1 medical examination within the centre was associated with an increased waiting time for surgery, whereas it was reduced by having an outpatient breast biopsy. The comprehensive cancer centre type was the only parameter associated with the other quality indicators. CONCLUSIONS: European Society of Breast Cancer Specialists quality indicators are a useful tool to evaluate care organisations. This study highlights the need for a standardised and coordinated preoperative clinical pathway.

[Efficacy of Management for Rational Use of Antibiotics in Surgical Departments at a Multi-Disciplinary Hospital: Results of a 7-year Pharmacoepidemiological Research].

Background: Irrational medicine use including excessive use and abuse of antibiotics remains a crucial problem for the healthcare systems. In this regard, studies examining approaches to improving the clinical use of medicines are highly important. Aim: to assess the efficacy rate of management for the rational use of antibiotics in surgical departments of a multi-disciplinary hospital. Material and Methods: The intervention complex combined the research, educational, and methodological activities: local protocols for perioperative antibiotic prophylaxis (PABP) for various surgical departments were developed; local PABP protocols were discussed with the physicians of specialized surgical departments; official order on implementation of PABP was issued; the list of drug prescriptions for registration of the first pre-operative antibiotic dose was changed; audit and feedback processes were introduced as well as consultations of a clinical pharmacologist were implemented. We assessed the efficacy rate of the interventions basing on the changes in consumption of antibiotics (both quantitatively and qualitatively) at surgical departments of a hospital using ATC/DDD methodology. Comparison of the studied outcomes was performed before and after the intervention implementation and between the departments (vascular and abdominal surgery). The consumption of antibacterial agents (ATCJ01) was measured as a number of defined daily doses (DDD) per 100 bed-days (DDD/100 bed-days, indicator recommended by the World Health Organization, WHO) and DDD per 100 treated patients (DDD/100 treated patients). Results: From 2006 to 2012, a decrease in antibacterial consumption in surgical departments by 188 DDD/100 treated patients was observed. We obtained the opposite results when using an indicator of DDD/100 bed-days (increase by 2.5 DDD/100 bed-days) which could be explained by the dependence on indices of overall hospital work and its changes during the examined period. Observed changes in antibacterial consumption varied in different surgical departments. The most pronounced positive changes were noted in the department of vascular surgery: decrease in total antibacterial consumption by 298 DDD/100 treated patients, decrease in the use of cephalosporins of the III generation from 141 to 38 DDD/100 treated patients. These positive changes were accompanied by the same (low) level of consumption/use of reserve antibiotics. In the department of abdominal surgery, there was no decrease in total antibiotic consumption, as well as in consumption of broad-spectrum cephalosporins of the III generation and fluoroquinolones, and we observed an increase in the use of reserve antibiotics (carbapenems) during the study period. Positive changes in antibiotic consumption were associated with the positive attitude of the manager/head of the department towards interventions: we observed the most pronounced decrease in antibiotic consumption straight after the publication of the administrative order on perioperative antibacterial prophylaxis. Conclusion: The combination of scientific, educational, and methodological interventions is effective for improving antibiotic application. The study results provide the rationale for analyzing the drug consumption using the DDD/100 treated patients measure in addition to the WHO-recommended indicator of DDD/100 bed-days which depends on overall hospital performance.

Hospital waste: can we reduce the environmental impact of a large university hospital?

Introduction: As technology advances, society must reflect on the destination of materials which are no longer needed. Hospital waste requires special attention due to the associated risk of disease transmission and biological accidents. Also, it tends to increase proportionally to the economic development and is associated with increased use of disposable material. The purpose of this study is to analyze the management of hospital waste at the Hospital de Clínicas de Porto Alegre (HCPA) and to evaluate the effectiveness and feasibility of the measures adopted by the institution to mitigate the impact of its waste on the environment. Methods: Observational study with field research. Hospital waste management is divided into generation, disposal, storage and final destination. Results: Between 2010 and 2015, the HCPA produced 21.4 tons of biological and sharps waste, 23,000 liters of chemical waste and 113,9 tons of solid waste per month. The main improvements include the implementation of a inspection of the hospital's waste bins every 2 months, a reduction from 29.42% to 2.79% in the rate of inappropriate disposal of hazardous waste, a 313% increase in investments in staff training, the expansion and adaptation of external areas for temporary storage of hospital waste and the collection of more than 1 ton of waste generated by the local community (sharps, X-ray films, kitchen oil, batteries), as well as the establishment of contracts which will guarantee the appropriate treatment of all types of health care waste. Conclusions: These results demonstrate that mitigating the impact of hospital waste on the environment is possible and should encourage the adoption of similar measures at other institutions (AU)

The impact of pharmacist certification on the quality of chemotherapy in Japan.

Background In the Japanese healthcare system, board certification not only maintains the quality of daily practice but is also required for hospitals to receive healthcare reimbursement. To date, no data on the effects of the board certification system in Japanese hospitals have been reported. Objective We performed a survey to clarify the impact of pharmacist certification on the quality of chemotherapy. Setting A nationwide mailing survey was conducted in Japan. Method We surveyed oncology pharmacists from 388 cancer designated hospitals (DHs) and 984 randomly selected general hospitals (GHs). Main outcome measure Multivariate analysis of factors for compliance with standard cancer chemotherapy to clarify the impact of pharmacist certification on the quality of chemotherapy. Results The response rate was 70.6 % (274/388) at the DHs and 43.4 % (428/984) at the GHs. Of the 13 different regimens, 66.1 % (181/274) of DHs and 64.7 % (277/428) of GHs reported having experienced either improper doses or intervals of drug administration. The median number of improper regimens was 1 at both the DHs (range 0-15) and GHs (range 0-22). We identified two groups of hospitals, those with two or more improper regimens and those with one improper regimen or less. Univariate analysis showed significant differences in the number of DHs (p < 0.01), performance of more than 10 chemotherapies per day (p < 0.05), presence of more than 400 beds (p < 0.01) and the professional qualifications of oncology pharmacists or medical oncologists. From multivariate analysis, significant differences were observed in certifications from the Japanese Society of Pharmacy Healthcare and Sciences certified Senior Oncology Pharmacist (odds ratio 0.29, p < 0.01) and the Japanese Society of Medical Oncology certified oncologist (odds ratio 0.48, p < 0.01). Conclusion Board certification was more prevalent in the designated (cancer specialist) hospitals than general hospitals and adherence to appropriate therapy was better when the DH was involved. Board certification was shown to be beneficial in terms of adherence to adequate chemotherapy.

Improvements in the management of neutropenic sepsis: lessons learned from a district general hospital.

Neutropenic sepsis is a life-threatening condition with mortality rates reported to range between 2 and 21% in adults. It can occur following chemotherapy treatment, due to disease (such as haematological conditions affecting the bone marrow) and in patients on disease-modifying agents (such as patients receiving methotrexate for rheumatoid arthritis). Appropriate emergency treatment is essential and achieving intravenous antibiotic door-to-needle time of less than 1 hour is a key target. Shortfalls in the management of patients presenting to teams with limited expertise in this area were identified in the National Confidential Enquiry into Patient Outcome and Death report in 2008, leading to recommendations including the need for an acute oncology service (AOS) at all hospitals with either an emergency department or medical admissions unit. Practice at Weston General Hospital has been audited at three time points since 2008 (in 2008, 2011 and 2013-14) during which there have been several service developments relevant to the management of neutropenic sepsis, including the introduction of an AOS in June 2013. The percentage of patients in which intravenous antibiotic 1-hour door-to-needle time was achieved has improved from 14% (2008) to 31% (2011) to 79% (2013-14) and neutropenic sepsis mortality has decreased from 39% (2008) to 14% (2011) to 0% (2013-14).

Ernest Amory Codman and the End-result System.

Ernest Amory Codman had an early penchant fondness for recording surgical complications and analyzing these recordings to determine a surgeon's ability along with a hospital's efficiency. This idea and the actions that followed suit in his career were not well received by his fellow colleagues. However, Codman's influence and spirit remained and helped shape important institutions in American medicine such as the The Joint Commission on Accreditation of Healthcare Organizations.

Code status discussions in psychiatric and medical inpatients.

BACKGROUND: The Patient Self-Determination Act along with regulatory standards and institutional standards of care highlight the need for collaboration between care providers and patients with respect to goals of care and, in emergency situations, code status and measures to be taken in keeping with patients' wishes. Addressing code status may be lacking in patients who require psychiatric hospitalization due to the nature of psychiatric illness, relative medical stability, and a general expectation of survival. We sought to compare code status documentation and discussion between psychiatric and medical inpatients, as this knowledge will help shape future interventions for process improvement. METHOD: We conducted a retrospective chart review of hospitalized patients in psychiatric and medical units during a 12-month period in 2008. For those with multiple admissions, we reviewed only the index (or first) hospitalization. Data collected included demographic information, clinical information regarding cancer as a primary diagnosis or a diagnosis that met National Hospice and Palliative Care Organization (NHPCO) guidelines, code status order and discussion documentation, the presence of an advance directive, length of stay, and 1-year mortality. Data were summarized using mean values, percentages, and frequencies. The 2 groups (psychiatric and medical groups) were compared. RESULTS: The charts of 276 psychiatric patients and 317 general medical patients were reviewed. More psychiatric patients had dementia (P < .001). Medical inpatients had a higher rate of code status order documented on admission (96% vs 65%, P < .001) and "full-code, discussed" order (67% vs 33%, P < .001). Psychiatric inpatients had more "do not resuscitate/do not intubate" orders (20% vs 13%, P = .037), more frequent changes in code status order (18% vs 7%, P < .001), and a higher percentage of advance directives (46% vs 25%, P < .001). CONCLUSIONS: A code status discussion with hospitalized patients needs to occur at admission regardless of reason for admission. Strategies are needed to improve this process for psychiatric inpatients.

Quality indicators for prostate radiotherapy: are patients disadvantaged by receiving treatment in a 'generalist' centre?

INTRODUCTION: The purpose of this retrospective review was to evaluate concordance with evidence-based quality indicator guidelines for prostate cancer patients treated radically in a 'generalist' (as distinct from 'sub-specialist') centre. We were concerned that the quality of treatment may be lower in a generalist centre. If so, the findings could have relevance for many radiotherapy departments that treat prostate cancer. METHODS: Two hundred fifteen consecutive patients received external beam radiotherapy (EBRT) and/or brachytherapy between 1.10.11 and 30.9.12. Treatment was deemed to be in line with evidence-based guidelines if the dose was: (i) 73.8-81 Gy at 1.8-2.0 Gy/fraction for EBRT alone (eviQ guidelines); (ii) 40-50 Gy (EBRT) for EBRT plus high-dose rate (HDR) brachytherapy boost (National Comprehensive Cancer Network (NCCN) guidelines); and (iii) 145 Gy for low dose rate (LDR) I-125 monotherapy (NCCN). Additionally, EBRT beam energy should be ≥6 MV using three-dimensional conformal RT (3D-CRT) or intensity-modulated RT (IMRT), and high-risk patients should receive neo-adjuvant androgen-deprivation therapy (ADT) (eviQ/NCCN). Treatment of pelvic nodes was also assessed. RESULTS: One hundred four high-risk, 84 intermediate-risk and 27 low-risk patients (NCCN criteria) were managed by eight of nine radiation oncologists. Concordance with guideline doses was confirmed in: (i) 125 of 136 patients (92%) treated with EBRT alone; (ii) 32 of 34 patients (94%) treated with EBRT + HDR BRT boost; and (iii) 45 of 45 patients (100%) treated with LDR BRT alone. All EBRT patients were treated with ≥6 MV beams using 3D-CRT (78%) or IMRT (22%). 84%, 21% and 0% of high-risk, intermediate-risk and low-risk patients received ADT, respectively. Overall treatment modality choice (including ADT use and duration where assessable) was concordant with guidelines for 176/207 (85%) of patients. CONCLUSION: The vast majority of patients were treated concordant with evidence-based guidelines suggesting that, within the limits of the selected criteria, prostate cancer patients are unlikely to be disadvantaged by receiving radiotherapy in this 'generalist' centre.

Discrepancy rates in liver biopsy reporting.

Medical liver biopsy reporting is challenging, and maintaining competency with small case numbers is potentially difficult. This study evaluates the discrepancies identified in cases referred to a specialist centre between the specialist reports and those of the referring general departments. Fifty consecutive recently referred cases were selected, and original and final reports were compared. Discrepancies were classified as per the Royal College of Pathologists guidelines and scored for potential clinical impact. The overall rate of discrepancy was 38% with most of these due to differences in interpretation of morphology. Seventy per cent of these discrepancies were judged to have major clinical impact (26% of all referred cases). This study highlights the need for robust systems of quality control of liver biopsies in a general setting.

Optimal resources for children's surgical care.

We will discuss a new initiative of the American College of Surgeons and the American Pediatric Surgical Association to prospectively define optimal resource standards for children's surgical care.

Filgrastim use in the emergency department of a Spanish general hospital.

BACKGROUND: Febrile neutropenia is a cause of dose reduction in hematological cancer treatments, with patient risk of infection proportional to duration and severity. In addition, colony-stimulating factors have been shown to be beneficial in a patient subgroup, although they are probably overused in the clinical setting. OBJECTIVE: Evaluation of compliance with American Society of Clinical Oncology 2006 criteria when it comes to filgrastim use in the Emergency Department of a Spanish general hospital. METHODS AND MATERIALS: A prospective observational study from August 2011 to February 2012 in a tertiary Spanish General Hospital. We included all patients prescribed with filgrastim in the Emergency Department. Data was collected on demographics, the pharmacotherapy history, the administered chemoprophylaxis, and the destination after discharge from a clinical department, the complete blood count, and the presence of fever >= 38 °C. RESULTS: 51 patients were recorded over the period of the study. 27.45% of prescriptions complied with the clinical practice guideline criteria given the risk of febrile neutropenia, whereas 72.34% of prescriptions did not comply with the criteria, 17.65% of which did not fulfil any requirements. CONCLUSIONS: A high percentage of colony-stimulating factors use in the Emergency Department does not comply with the medical practice guideline.