Hospital preparedness and response in CBRN emergencies: TIER assessment tool.

INTRODUCTION: Chemical, biological, radiological, and nuclear (CBRN) emergencies need particular hospital preparedness and resources availability. Also, specific skills and capabilities are required for efficient response to these types of events. The aim of this study was to develop an assessment tool to evaluate hospital preparedness and response performance with respect to CBRN emergencies. METHODS: An evaluation tool was developed using the Delphi technique. A panel of experts from 10 countries, both European and non-European, with more than 5 years of experience in research or practice in CBRN emergency management was involved in this study. The study was run online, and the experts were asked to evaluate a list of items on hospital preparedness and response in CBRN emergencies. A threshold of 85% agreement level was defined as the consensus of experts in this study. RESULTS: The first-round questionnaire was answered by 13 experts. Consensus on the preparedness section was reached for all 29 items during the first round and one item was also added by the experts. Consensus on the response performance indicators were reached in 51 out of the 59 items, during the first round, and eight items were modified and then approved in the second round by the experts. CONCLUSION: Hospitals need a specific level of preparedness to enable an effective response to CBRN emergencies. The assessment tool, developed through experts' consensus in this study, provides a standardized method for the evaluation of hospital preparedness and response performance with respect to CBRN emergencies. The feasibility and reliability of this assessment tool could be evaluated before and during simulated exercises in a standardized manner.

Key Aspects of a Sustainable Health Insurance System in Germany.

BACKGROUND: The main goals of health-care systems are to improve the health of the population they serve, respond to people's legitimate expectations, and offer fair financing. As a result, the health system in Germany is subject to continuous adaption as well as public and political discussions about its design. OBJECTIVE: This paper analyzes the key challenges for the German health-care system and the underlying factors driving these challenges. We aim to identify possible solutions to put the German health-care system in a better position to face these challenges. METHODS: We utilize a broad array of methods to answer these questions, including a review of the published and grey literature on health-care planning in Germany, semi-structured interviews with stakeholders in the system, and an online questionnaire. RESULTS: We find that the most urgent (and manageable) aspects that merit attention are holistic hospital planning, initiatives to increase (administrative) innovation in the health-care system, incentives to increase prevention, and approaches to increase analytical quality assurance. CONCLUSION: We found that hospital planning, innovation, quality control, and prevention, are considered to be the topics most in need of attention in the German health system.

Stent for Life Initiative placed at the forefront in Egypt 2011.

AIMS: Myocardial infarction is a medical emergency in which 25 to 35% of patients will die before receiving medical attention. The Stent for Life registry was launched to access the current situation of the Egyptian population presenting with STEMI, and to determine what were the barriers to providing patients with cardiac problems appropriate care. METHODS AND RESULTS: This registry was conducted at 14 centres covered all the Egyptian regions including 1,324 consecutive patients presenting with STEMI during the period between January 1st, 2011 to November, 2011. Fourteen centres and 38 interventionalists participated in this registry; only six centres are Pilot Centres (fulfilling the criteria for a primary PCI centre) and were assigned at the end of 2011. Cardiovascular risk factors were mainly smoking (60.5%), dyslipidaemia (46.0%), diabetes (51.4%) and hypertension (56.0%). The mean age at presentation was 56.01±10.61years and 75.0% were male. Only 5% of the STEMI patients arrived via the emergency medical system. Thrombus aspiration was done in 42.7% of patients in primary PCI group and 25.9% in rescue PCI group. Bare metal stents (BMS) were used in 80.7% of the stented patients while drug eluting stents (DES) were used in 19.3% of the stented patients. In-hospital mortality was 2.9% (1.4% in primary PCI group, 1.1% in patients treated with thrombolysis and 0.4% in patients receiving no reperfusion therapy). CONCLUSION: Despite the logistical difficulties, excellent outcomes for acute interventional reperfusion strategy in STEMI can be achieved in our country, possibly similar to those seen in the West. There is a strong need for making the practice of PCI in STEMI more widespread in developing regions.

Stent for Life Initiative--the Greek experience.

Primary percutaneous coronary intervention (p-PCI) is considered the gold standard reperfusion strategy for patients with ST-elevation myocardial infarction (STEMI). In the last two years, the Stent for Life (SFL) Initiative has aimed at expanding the use of p-PCI in Greece and several other European countries. During this short period of time, intensive efforts towards propagating the main objectives of the programme in Greece and important actions on the organisation and activation of two p-PCI networks in Athens, the Greek capital, and Patras in south-western Greece, have led to a dramatic nationwide increase of p-PCI rates among STEMI patients (from 9% to 32%). Especially in Athens, p-PCI is implemented in almost 60% of the cases with a diagnosis of STEMI. Recent data from the Greek national registry on acute coronary syndromes underscore the need to improve p-PCI time delays which are partially attributed to inter-hospital delays from hospitals with no p-PCI facilities to p-PCI hospitals. A national public campaign for the promotion of p-PCI is progressing very fast, while specific planning for the recruitment of additional hospitals in urban and rural areas to join old, or to form new p-PCI networks is still developing.

Mentality and organisational changes are key to developing primary angioplasty.

At the moment of signing the Stent for Life (SFL) Initiative on August 31st, 2009, it was shown that, in Serbia during 2008, 48% of patients with ST-elevation myocardial infarction (STEMI) did not receive any reperfusion and only 19% and 33% received primary percutaneous coronary intervention (p-PCI) or hospital thrombolysis, respectively. However, during 2009, there was a trend towards a substantial increase in p-PCI procedures. This was the result of the commitment of cardiologists, the contract signed by the Health Insurance Fund (HIF) for remuneration of catheterisation laboratory (cathlab) staff for each p-PCI procedure (2005), and the provision of new cathlabs by the Ministry of Health (MOH). The number of PCI centres and trained cardiologists has been rising simultaneously. Direct mobile telephone contact with interventional cardiologists has facilitated the transport of patients directly to cathlabs (from 7.5% before 2009 to 34.2% in 2010 and 2011). Although the number of patients treated with p-PCI is increasing (2006 - 647 p-PCIs; 2007 - 1,248 p-PCIs; 2008 -1,794 p-PCIs; 2009 - 2,468 p-PCIs; 2010 - 3,216 and 2011 - 3,498 p-PCIs), the percentage of patients who are treated within 120 minutes of establishing a diagnosis (first medical contact) is still not satisfactory (38%).

Primary percutaneous coronary intervention: models of intervention in Spain.

Early reperfusion of the occluded artery is the mainstay of the treatment of ST-segment elevation myocardial infarction (STEMI), and the best way to coordinate the resources to deliver optimal care as soon as possible is through STEMI networks. Coordination of the healthcare system is the responsibility of each of the 17 different autonomous communities in Spain. Since 2002, when the first STEMI network in Spain was established, six other communities have developed regional networks, covering 39% of the population in Spain. In the autonomous communities, after implementing an intervention model, an improvement in the reperfusion times with an increase in the number of primary percutaneous coronary interventions has been observed. This optimisation of the system has resulted in a decrease in the mortality rate among STEMI patients treated in Spanish communities with a STEMI network. Despite the encouraging advances, the challenge remains of assuring equity of treatment for all of our patients regardless of their region of residence.

Developing primary PCI as a national reperfusion strategy for patients with ST-elevation myocardial infarction: the UK experience.

In 2004 in the United Kingdom (UK), the infrastructural and organisational changes required for implementation of primary PCI for treatment of STEMI were unclear, and the cost-effectiveness and sustainability of a changed reperfusion strategy had not been tested. In addition, any proposed change was to be made against the background of a previously successful in-hospital thrombolysis strategy, with plans for greater use of pre-hospital administration. A prospective study (the "National Infarct Angioplasty Project - NIAP") was set up to collect information on all patients presenting with STEMI in selected regions in the UK over a one year period (April 2005 - March 2006). The key findings from the NIAP project included that PPCI could be delivered within acceptable treatment times in a variety of geographical settings and that the shortest treatment times were achieved with direct admission to a PPCI-capable cardiac catheter laboratory. The transformation from a dominant lytic strategy to one of PPCI across the UK was achieved both swiftly and consistently with the help of 28 cardiac networks. By the second quarter of 2011, 94% of those STEMI patients in England who received reperfusion treatment were being treated by PPCI compared with 46% during the third quarter of 2008.

Decreasing STEMI mortality by implementing a PPCI network in Bulgaria.

This article describes the development of the p-PCI network in Bulgaria. Even though interventional treatment of STEMI in the country was introduced around 1990, it was not performed on a regular basis which made it largely inefficient. The paper tracks the network evolution with all the problems encountered and the solutions undertaken until the present moment. Historically, all the important factors concerning the implementation, such as spreading of PCI centres, networks and infrastructure, training and certification, emergency medical service, public awareness campaigns, 24/7 work, reimbursement, etc., are reviewed. Finally, the current increase of the percentage of STEMI patients treated by p-PCI and the decrease of overall STEMI mortality rates are shown, clearly demonstrating the huge value of the SFL know-how and contribution.

Designing a model for trauma system management using public health approach: the case of Iran.

Trauma is a leading cause of death and disability around the world. Injuries are responsible for about six million deaths annually, of which ninety percent occur in developing countries. In Iran, injuries are the most common cause of death among age groups below fifty. Trauma system development is a systematic and comprehensive approach to injury prevention and treatment whose effectiveness has been proved. The present study aims at designing a trauma system management model as the first step toward trauma system establishment in Iran. In this qualitative research, a conceptual framework was developed based on the public health approach and three well-known trauma system models. We used Benchmarks, Indicators and Scoring (BIS) to analyze the current situation of Iran trauma care system. Then the trauma system management was designed using the policy development phase of public health approach The trauma system management model, validated by a panel of experts, describes lead agency, trauma system plan, policy-making councils, and data-based control according to the four main functions of management: leading, planning, organizing and controlling. This model may be implemented in two phases: the exclusive phase, focusing on resource integration and the inclusive phase, which concentrates on system development. The model could facilitate the development of trauma system in Iran through pilot studies as the assurance phase of public health approach. Furthermore, the model can provide a practical framework for trauma system management at the international level.

Leading quality through the development of a multi-year corporate quality plan: sharing The Ottawa Hospital experience.

This article discusses the background and process for developing a multi-year corporate quality plan. The Ottawa Hospital's goal is to be a top 10% performer in quality and patient safety in North America. In order to create long-term measurable and sustainable changes in the quality of patient care, The Ottawa Hospital embarked on the development of a three-year strategic corporate quality plan. This was accomplished by engaging the organization at all levels and defining quality frameworks, aligning with internal and external expectations, prioritizing strategic goals, articulating performance measurements and reporting to stakeholders while maintaining a transparent communication process. The plan was developed through an iterative process that engaged a broad base of health professionals, physicians, support staff, administration and senior management. A literature review of quality frameworks was undertaken, a Quality Plan Working Group was established, 25 key stakeholder interviews were conducted and 48 clinical and support staff consultations were held. The intent was to gather information on current quality initiatives and challenges encountered and to prioritize corporate goals and then create the quality plan. Goals were created and then prioritized through an affinity exercise. Action plans were developed for each goal and included objectives, tasks and activities, performance measures (structure, process and outcome), accountabilities and timelines. This collaborative methodology resulted in the development of a three-year quality plan. Six corporate goals were outlined by the tenets of the quality framework for The Ottawa Hospital: access to care, appropriate care (effective and efficient), safe care and satisfaction with care. Each of the six corporate goals identified objectives and supporting action plans with accountabilities outlining what would be accomplished in years one, two and three. The three-year quality plan was approved by senior management and the board in April 2009. This process has supported The Ottawa Hospital's journey of excellence through the creation of a quality plan that will enable long-term measurable and sustainable changes in the quality of patient care. It also engaged healthcare providers who aim to achieve more measured quality patient care, engaged practitioners through collaboration resulting in both alignment of goals and outcomes and allowed for greater commitment by those responsible for achieving quality goals.

[Clinical leaders' and staff's assessment of the current quality related to the patient pathways and expectations of and knowledge about accreditation--a baseline evaluation in Copenhagen County]. / Lederes og medarbejderes vurdering, forventninger og kendskab til akkreditering--en førmåling på sygehuse i Københavns Amt.

INTRODUCTION: In the preparation for accreditation in Copenhagen County the commitment of clinical leaders and staff members is crucial. The objectives of these surveys are to examine the leaders' and the staff's assessment of quality improvement and their expectations and knowledge about accreditation, as well as the staff's advice concerning the further planning. MATERIALS AND METHODS: Two surveys among clinical leaders and staff members were carried out. RESULTS: Statistically, significant differences between staff and leaders were found in many areas concerning quality improvement and knowledge about accreditation. Leaders and staff both had high expectations of the use of accreditation as a tool for quality improvement, thus no statistically significant difference between expectations were found. CONCLUSION: The overall positive expectation for accreditation as a tool for quality improvement is an excellent basis for the accreditation process. The different assessments in quality among leaders/staff and positions show the need to involve all personnel in the organization. A survey about patient experiences includes the same subjects as the survey among staff and leaders. A striking discrepancy between the evaluation of quality by patients and by the leaders and staff in specific areas was found; therefore further investigations will be carried out.

Setting priorities in health care organizations: criteria, processes, and parameters of success.

BACKGROUND: Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly. DISCUSSION: We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making. SUMMARY: Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly.

Exploring distributive justice in health care.

The allocation of resources to providers and the way in which the resources are then prioritised to specific service areas and patients remain the critical ethical decisions which determine the type of health system a community receives. Health care providers will never be given enough resources to satisfy all the demands placed upon them by a community that is becoming increasingly informed and demanding. This paper discusses the matter of justice as it relates to the distribution of health resources. It translates the theoretical constructs of distribution into a practical situation that arose at The Geelong Hospital. It is important to emphasise that the aim of giving the example is not necessarily to provide the right answer but rather to assist in determining what ought to be the questions.