Sequential measurements of procalcitonin levels in diagnosing ventilator-associated pneumonia.

The utility of procalcitonin levels to improve the accuracy of clinical and microbiological parameters in diagnosing ventilator-associated pneumonia (VAP) was evaluated. Sequential measurement of procalcitonin and C-reactive protein levels and the calculation of the simplified Clinical Pulmonary Infection Scores (CPIS) were performed in 44 patients mechanically-ventilated for >48 h with neither active infection for the duration or suspicion of VAP. Patients who developed extrapulmonary infection were excluded. In total, 20 cases were suspected of having VAP and diagnosis was microbiologically confirmed in nine. In patients with confirmed VAP, procalcitonin levels were higher than in those without VAP. C-reactive protein levels and CPIS were lower in patients without suspected VAP, but could not discriminate confirmed and nonconfirmed suspicion of VAP. The best sensitivity and specificity (78 and 97%, respectively) corresponded to procalcitonin. The CPIS resulted in the same sensitivity, but had a lower specificity (80%). C-reactive protein had the worst sensitivity (56%), but a good specificity (91%). A CPIS >or=6 combined with serum levels of procalcitonin >or=2.99 ng.mL(-1) did not improve the sensitivity (67%), but resulted in 100% specificity. Procalcitonin might be useful in the diagnosis of ventilator-associated pneumonia. Combined values of Clinical Pulmonary Infection Scores and procalcitonin below the cut-off points excluded false-positive diagnoses of ventilator-associated pneumonia.

Perioperative antibiotic prophylaxis in Spanish hospitals: results of a questionnaire survey. Hospital Pharmacy Antimicrobial Prophylaxis Study Group.

A questionnaire survey was sent to a random sample of the Spanish network of National Health System public acute-care hospitals. Of responding institutions (representing 25% of Spanish hospital beds), nearly 75% had active surveillance programs for the prevention and control of surgical-site infections (SSIs), but only 20% performed postdischarge surveillance. Overall, perioperative antibiotic prophylaxis (PAP) was used in 84% of all surgical procedures. For 77% of procedures, there were written guidelines for the choice and use of PAP. Cefazolin was the most commonly used antibiotic (38%). Duration of PAP was shorter than 24 hours in 75% of procedures, and only a single dose was given in 52% of procedures. PAP was commonly used in breast (52%) and inguinal hernia repair (69%) procedures, as well as in laparoscopic abdominal surgery (86%). In summary, the use of PAP in Spanish hospitals is adequate, but improvements can be made in the frequency of prolonged PAP and in the use of broad-spectrum antibiotics. Surveillance systems for SSI, including postdischarge follow-up, also should be improved.

Prevention and control of nosocomial infections in Spain: current problems and future trends.

Spain is a state member of the European Union, with more than 180,000 hospital beds and 800 public and private institutions. Only 6.9% of our gross national product is devoted to health expenditures. All citizens receive free health care through the National Health System. This system has given increasing attention to the prevention and control of nosocomial infections since 1986. In this article, results of serial prevalence surveys of antibiotic use and resistance patterns of microorganisms isolated from nosocomial infections are discussed. The needs for future development of infection control and quality assurance training programs in Spain also are discussed. Overall, a clinically and epidemiologically oriented approach to infection control is preferred, with greater emphasis in the role of infection control practitioners and infection control committees.

Information as a fundamental attribute among outpatients attending the nuclear medicine service of a university hospital.

The aim of this study was to assess outpatients' satisfaction with the service received in the nuclear medicine service of the Hospital Clinic i Provincial of Barcelona in February 1993. The patients were randomly assigned to one of two groups: group 1 received information about their diagnostic procedure, whereas group 2 did not (a control group). A questionnaire was used to assess patients' degree of satisfaction. The questionnaire was administered to 803 patients, 243 (30.26%) of whom completed it and returned it. The following factors were significantly related to high scores on the satisfaction scale: age (P < 0.015), waiting time (P < 0.001), treatment by assisting personnel (P < 0.001), treatment by personnel at the service reception (P < 0.01), waiting room habitability (P < 0.01), communication variables (P < 0.03) and low scores on the anxiety scale (P < 0.02). Group 1 perceived more positively treatment by personnel at reception (P < 0.041), treatment by assisting personnel (P < 0.027), waiting room habitability (P < 0.035) and communication variables (P < 0.001). The anxiety scale scores among this group were significantly lower. We conclude that when information is supplied to patients, their anxiety decreases before a diagnostic procedure, which significantly improves their perception of the factors that generate satisfaction among patients.

Perceived quality of care in pregnancy assessment before and after delivery.

OBJECTIVE: To assess the perceived quality of care in a group of pregnant women attended in a public Hospital. STUDY DESIGN: All pregnant women seen at the Hospital Clinic of Barcelona in 1996. Two study groups were defined: group A, women seen at the outpatient clinic as a regular follow-up visit for pregnancy, and group B, women seen at the outpatient clinic for follow-up after delivery. A satisfaction questionnaire survey was used in a random sample of both groups of women. RESULTS: Total number of interviews performed was 174. Both groups, A and B were comparable. Scores recorded in both groups were significantly different (P<0.01) for the clinical follow-up and privacy variables (regarded as better than expected). The difference in scores for the information supplied was also statistically significant (P<0.01), but regarded as worst than expected. CONCLUSIONS: The analysis of satisfaction does not seem to follow a linear, straightforward explanation. The differences seen strongly suggest the need of patient's satisfaction surveys to be specific by dimension and tailored to patients' expectations.

Perceived quality of care of inguinal hernia repair: assessment before and after the procedure.

OBJECTIVE: Assessment of the perceived quality of care for inguinal hernia repair procedures. DESIGN: A two-step descriptive study using specific questionnaires. SETTING: A tertiary care University Hospital. SUBJECTS: Random sample of patients diagnosed of inguinal hernia in 1996. Group A, patients seen at the outpatient clinic before admission; group B, patients seen for follow-up after the surgical procedure. INTERVENTIONS: Two different questionnaires were used. MAIN OUTCOME MEASURES: validity of the questionnaire was evaluated using Cronbach's alpha value. Scores were measured using the z value. RESULTS: Total number of patients was 194. Both groups were comparable. The questionnaire was able to explain 66.3% of the variance. The Cronbach's alpha value was 0.90. Scores recorded were significantly different (P < 0.01) regarding the health care workers' attitude and hospital commodities' variables (rated as better than expected). Differences in scores for information supplied, overall results of the surgical procedure and food variables were not statistically significant. CONCLUSIONS: (i) The study of several fields where the patient's expectations are higher or lower contributes to prioritizing efforts to improve quality in the Surgery Department. (ii) The differences seen strongly suggest the need for patient's satisfaction surveys to be specific by diagnosis/dimension and adapted to patients' expectations.

Appropriateness of admissions and hospitalization days in an acute-care teaching hospital.

A cross-sectional study was made of the appropriateness of admissions and hospitalization days in an high-technology, acute-care teaching hospital. This 952-bed institution with 31 hospital services is a reference center for the metropolitan area of Barcelona. A systematic random sampling (1:11) of the registers of hospital discharges was carried out during the months of January, February and March 1991 (n = 7,142) excluding discharges from the pediatric, obstetrics and psychiatric departments. A retrospective analysis was made of 639 patients' medical records using the Appropriateness Evaluation Protocol (AEP). The rate of inappropriate hospital admissions was 9.1% (58/639) (95% confidence interval: 6.9-11.5). Inappropriate admissions were primarily attributable to hospitalizations for diagnostic and/or therapeutic services that could have been rendered on an ambulatory basis (70.7% of cases). Overall 29.2% of hospitalization days (1,963/6,731) were inappropriate (95% confidence interval: 28.1-30.3). Inappropriate admissions to hospital, an optimizable health care planning and a conservative physician's attitude (postponed discharge) were the most frequent reasons for unnecessary days of care. The interrater reliability in the use AEP criteria for appropriateness of admission showed a kappa index of 0.5 and that for appropriateness of hospitalization days 0.67. In summary, instruments, such as the AEP protocol, that allow us to determine which patients can be attended at other levels of the health care system and which levels are the most appropriate, are key elements in improving the appropriateness of hospital use in public health care systems.

[Assessment of the performance of sabbatical leave: Hospital Clínic i Provincial of Barcelona (1990-1991). Research Committee of the Hospital Clínic i Provincial of Barcelona]. / Evaluación del rendimiento de los permisos sabáticos: Hospital Clínic i Provincial de Barcelona (1980-1991). Comité de Investigación del Hospital Clínic i Provincial de Barcelona.

BACKGROUND: The development of an evaluation protocol for assessing the scientific contribution and the impact on medical care of the sabbatical leaves granted in a large Spanish teaching hospital. METHODS: The sabbatical leaves for all faculty staff of the Hospital Clínic i Provincial of Barcelona (HCPB) were analyzed since 1980 trough 1991. The scientific production analysis was done according to the impact factor (IF) score of the Science Citation Index. Descriptive statistical techniques as well as parametric and non-parametric tests were used for comparisons. RESULTS: A total of 52 sabbatical leaves was analyzed of all 60 leaves granted (87%). Mean duration of the leave was 7.94 +/- 3.86 months. The scientific production includes 89 original articles published in peer-reviewed medical journals, with a total score of 300.82 IF points (mean score: 5.78 +/- 7.12 IF points by leave). There were significant differences in the mean duration, number of papers published and IF points score by sabbatical leave between the Medicine, Surgery and Other Departments. In 16 cases (31%) there was a professional promotion following the sabbatical leave and in 20 cases (39%) an academic promotion. In 27 cases (60%) there was no promotion after the leave. Most of the faculty staff physicians (96%) are still employed in the same institution, and believe that the sabbatical leave has significantly contributed to their promotion (67%). A high percentage (94%) has also been able to develop afterwards the methods and techniques learned during the sabbatical leave. CONCLUSIONS: The experience of the Hospital Clinic of Barcelona in granting sabbatical leaves has been highly positive. The scientific performance of the individuals on leave is high. Our institution has been able to add and develop most of the techniques and methods learned overseas. The future of the sabbatical leaves in other Spanish Universities and Hospitals should be regarded as a high priority target. The performance of these leaves is supported by its scientific results, that could be quantified.

[Risk of nosocomial infection in elderly patients admitted to a university hospital]. / Riesgo de infección nosocomial de los pacientes ancianos ingresados en un hospital universitario.

BACKGROUND: A high percentage of current hospital visits are made by the elderly. The aim of this work is to quantify the risk of contracting a nosocomial infection among elderly patients admitted to a university hospital. METHODS: From the patients admitted from the emergency unit, outpatients and the waiting list, 6 patients of different age groups were chosen each day by a simple random sampling. The criteria of nosocomial infection were those of the CDC. The analysis of the information was made with the programme EPIINFO version 5. The chi 2 tests and Fisher's exact test were used to compare proportions. RESULTS: The rate of nosocomial infection in the group aged over 64 was 14.8%, showing statistically significant differences with respect to other age groups (p = 0.001). In this group the predominant infection was urinary, with an odds-ratio of 3.69, in comparison with the 25 to 44 age group. A prolonged hospital stay (> 15 days) has proved to be closely related to the risk of nosocomial infection in all age groups (p < 0.0001) in patients over 64. CONCLUSIONS: The greater risk of contracting nosocomial infections in the elderly makes it advisable to develop specific prevention programmes for this group, and the fitness of accommodations the length of stay to the care needs suitable to the hospital level.

[Comparative analysis of articles published by Spanish authors (1993-1997) in biomedical journals with high impact factor]. / Análisis comparativo de las publicaciones realizadas por autores españoles (1993-1997) en revistas clínicas con factor de impacto elevado.

BACKGROUND: To identify the Spanish scientific production amongst different areas of clinical knowledge, and to compare it with those of five other European Union countries. METHOD: Review of MEDLINE data base, for the period 1993-1997. Search limited to four journals, selected, for 10 different medical specialties (Cardiology, Endocrinology, Infectious Diseases, Gastroenterology-Hepatology, Haematology, Nephrology, Pneumology, Neurology, Oncology, Rheumatology). Articles published by authors from Germany, France, Italy, The Netherlands, Sweden and Spain. Journals included in the Internal Medicine subject classification were independently analysed. Data were also related with several econometric indexes. RESULTS: A total of 1,763 original articles published by Spanish authors were identified in the journal's sample over the analysed period (2.08 articles per 100 all published articles). Spain contributes to the total achieved by the six European countries analysed with 9.07 articles per 100 published articles. Gastroenterology-Hepatology was the medical specially which has more articles published by Spanish authors (total: 338 articles; 4.15 articles/100 published articles); and Oncology the one with less articles published (1.26 articles/100 published articles). The mean IF value per journal by article is highest for Gastroenterology-Hepatology (4.86 FI/article) and lowest for Pneumology (2.42 FI/article). Spain is the last amongst all six European countries analyzed in Endocrinology, Oncology and Haematology, and second to last in all others except for Gastroenterology-Hepatology (4th place). Mean cost for each article produced by Spanish authors in the analyzed sample was 0.49 US $ according the health expenditures per capita, and 0.07 US $ according the R+D expenditures per capita. Data from the independent analysis of Internal Medicine journals also showed that Gastroenterology and Hepatology is the subspecialty with a higher number of papers published in those journals. CONCLUSIONS: All efforts devoted to improve the quality of Spanish biomedical research, specially in clinical research, had produced positive, but uneven, results, measured by the number and impact factor of original articles published in top ranked biomedical journals. The overall distribution of high impact factor scientific production by specialties is poor when compared to the European Union countries included in the analysis. Those results showed several improvement opportunities. Besides increasing the overall budget for R+D, its is likely that the time has come for backing the highest quality Spanish biomedical research, the one that offers greater and better chances for achieving scientifically valid results, and is published in high impact factor biomedical journals.

[Impact of sabbatical leave on hospital and university promotions]. / Influencia de los permisos sabáticos en la promoción hospitalaria y universitaria.

BACKGROUND: The aim of this study was the assessment of the scientific production and impact on academic and/or hospital promotion ob sabbatical leaves of medical staff from a University hospital. POPULATION AND METHODS: A matched case-control design was used. The Mantel-Haenszel odds ratio (ORMH) and its 95% confidence intervals were calculated. A total of 52 sabbaticals leaves were analyzed with successful matching for 43 pairs. RESULTS AND CONCLUSIONS: Taking a sabbatical leaves is associated with a significant higher chance of hospital promotion (ORMH = 7.5; CI 95%, 1.71-32.78; o = 0.004), but there is not a significantly higher chance of academic promotion (ORMH = 0.66; CI del 95%, 0.23-1.83; p = 0.60).

[Assessment of patients' expectations before admission to a tertiary-care center]. / Evaluación de las expectativas de los pacientes antes del ingreso en un centro de tercer nivel.

BACKGROUND: The customer's final satisfaction with health services depends to some extent, on the relationship between expectancy and perceived quality. Focus groups technique helps in the knowledge of those attributes that patients identified as perceived quality. MATERIAL AND METHODS: The study was performed in the Hospital Clínic i Provincial of Barcelona (HCPB), Spain, by selecting a sample of patient's included in the admission's waiting list (1994) of three common procedures: lens extraction, abdominal hernia repair and routine pregnancy control. The patients were distributed in 12 different semi-structured interview groups (focus groups) and video-taped. From the analysis of those tapes, the main concerns and aspects highlighted by consumers were identified, following a common set of rules: wording, context, internal consistency, precision/vagueness of answers and basic ideas. RESULTS: A total of 106 patients attend the interview. Patients with loss of visual acuity underscore the contribution of quality of life improvement expected from the procedure (technical quality of the surgical procedure, physical improvement and final outcomes). Patient's with abdominal hernia repair highlight the appearance and comfort of hospital setting as the most important item. Pregnant women emphasize the importance of a good follow-up process after delivery, as well as the need for individual services (dignity and intimate). CONCLUSION: The semi-structured interview method (focus group) could be applied in the context of our hospitals, and contribute to improve quality management at our institutions, making effective the patient participation.

[Excess length of stay attributable to nosocomial bacteremia: usefulness of the Hospitalization Appropriateness Protocol]. / Prolongación de la estancia atribuible a la bacteriemia nosocomial: utilidad del Protocolo de Adecuación Hospitalaria.

BACKGROUND: To evaluate the usefulness of the Appropriateness Evaluation Protocol (AEP) for assessing the extra length of stay attributable to nosocomial bacteremia. PATIENTS AND METHODS: Retrospective review of the medical records (1989, 1990 and 1991) of all patients, who developed Staphylococcus aureus nosocomial bacteremia. Evaluation of hospital stay was performed using the AEP. Calculation of the kappa index and intraclass correlation coefficient. RESULTS: A total of 158 patients were included S. aureus nosocomial bacteremia is responsible for a mean excess length of stay of 4.3 days per patient. Kappa index for the method used was 76%, and intraclass correlation coefficient was 61%. CONCLUSIONS: The AEP has been shown to be a reliable tool for assessing the extra days of stay attributable to nosocomial bacteremia in the Spanish National Health System. The use of AEP should be extended to assess the extra stay attributable to other types of nosocomial infections.

[Impact of hospital admissions for pneumonia in a tertiary Spanish hospital]. / Impacto sanitario de los ingresos por neumonía en un hospital de tercer nivel.

BACKGROUND: Impact of hospital admissions for pneumonia during 1998 in the Hospital Clínic, Barcelona. PATIENTS AND METHOD: Retrospective information on the hospitalizations for pneumonia was collected. RESULTS: During 1998 a total of 626 adult were admitted with a hospital diagnosis of pneumonia (72% were >/= 65 years). The average length of stay was 10 days. Half of these patients were previously hospitalized during the preceding 5 years. CONCLUSIONS: Hospital admissions due to pneumonia (17 cases per 1.000 hospitalizations) accounted for an estimated cost of 2.3% of the cost of all the hospitalized patients.

[The vaccination of medical and nursing students against hepatitis B]. / Vacunación de estudiantes de medicina y enfermería frente a la hepatitis B.

BACKGROUND: Vaccination against the hepatitis B virus (HBV) of health care staff during their studies would have the advantage of early prevention when the prevalence of infection is presumably low. METHODS: The population to be protected is made up of 1533 medical and nursing students. In those who accepted, anti-HBc was determined and information was obtained concerning circumstances of exposure to HBV. Vaccination was offered to all the cases of negative anti-HBc. Individuals receiving 3 doses of the vaccination (20 micrograms at 0, 1 and 6 months) were seen at 4-7 months of the last dose to determine the anti-HBs titers achieved. RESULTS: One thousand sixty-five students (70%) accepted inclusion into the prevaccination anti-HBc study and 1,029 (3.4%) were anti-HBc negative. Only older age and previous transfusions and jaundice were significantly associated to greater prevalence of infection by HBV. The adherence to 1, 2 or 3 doses of the vaccination was 96%, 94% and 87%, respectively. Following the 3 doses, > or = 10 UI/I of anti-HBs were detected in 97% of the cases studied with geometric measurement of the responders being 1580 U/I. The titer had an inverse relation which was not significant with age. CONCLUSIONS: The high participation in the program of anti-hepatitis B vaccination and the excellent immune response observed leads to the recommendation of systemic vaccination to future health care professionals during their study period. Furthermore, the low prevalence of previous HBV infection advises against previous detection of anti-HBc with immunization of the whole collective being more effective.

[Nosocomial infections due to opportunistic fungi: analysis of a news outbreak in the Spanish press]. / Infecciones nosocomiales por hongos oportunistas: análisis de una serie de noticias publicadas en la prensa española.

BACKGROUND: To study an outbreak of media news related to nosocomial infections due to opportunistic fungi in Spanish hospitals. CASE DEFINITION: any news related to possible nosocomial infection due to opportunistic fungi in Spanish hospitals, published in national or local daily newspapers, over the pre-epidemic (July-December, 1998) and epidemic periods (January-June, 1999). All news were reviewed and identified using global press reports summaries, prepared by two independent sources, and were analyzed by three different observers. RESULTS: Over the pre-epidemic period there were not any news related to nosocomial infections due to opportunistic fungi. Over the epidemic period, a total of 218 news were identified, 154 (71%) published in national newspapers and 64 (29%) in local ones. We analyzed separately 18 editorials or opinion articles related to this subject. The epidemic curve (distribution of news by week) showed an incidence news peak at week 5 (102 news, 46.7% of all news published). The media mentioned up to 19 different hospitals as institutions with possible cases of nosocomial fungal infections. After week 8, news incidence drop, and remain thereafter at minimum levels. CONCLUSIONS: The example provided by the analysis of this outbreak of media news, related to nosocomial infections by Aspergillus an other opportunistic fungi, is useful to allow us understand how some medical news arise, develop and were transmitted. The public alert situation created in Spain was remarkable, and it is likely that there was a transient loss of confidence in the safety of public health institutions. Today's medicine requires a great and better openness to the media, and a better cooperation between both parts.

[Susceptibility to measles, rubella and parotitis in young adults]. / Susceptibilidad al sarampión, rubéola y parotiditis en adultos jóvenes.

BACKGROUND: The aim of this study was to know the prevalence of antibodies against measles, rubella and parotiditis in young adults. METHODS: The study was carried out in health care students during the academic year of 1992-1993. Demographic and geographic variables were obtained as were vaccination and history of diseases. Antibodies against measles, rubella, and parotiditis were determined by ELISA techniques with commercial reagents. RESULTS: Three hundred and six individuals of 21.3 +/- 2.2 years (range 17-36 years) with 27.5% being males were studied. Past history of measles, rubella and parotiditis was reported in 43.5, 30.7 and 37.3%, respectively, with vaccination being 23.2, 43.8 and 20.6%, respectively. The prevalence of antibodies was 93.1% (measles), 96.4% (rubella) and 92.1% (parotiditis). CONCLUSIONS: The prevalence of infection of measles, rubella and parotiditis in the young population studied is mainly due to infection by wild type virus. The foreseeable growth of susceptibility groups in this population which should be adequately evaluated by extensive seroepidemiologic questionnaires, favors the appearance of epidemic outbreaks. The use of the triple viral vaccine is suggested as an alternative to rubella vaccination in presumable susceptible young women.

[Epidemiologic surveillance system for reportable diseases at the hospital]. / Sistema de vigilancia epidemiológica de enfermedades de declaración obligatoria en el hospital.

The aim of this work is to present a detection system of reportable diseases among patients attending a teaching hospital. Since January 1988, based on daily data obtained from the Admissions Department of Hospital Clínic of Barcelona (HCP) (emergency department visits and hospital admissions and discharges), the Preventive Medicine Unit identifies every day those diseases considered as reportable by the Department of Health of Catalonia, Spain. Reported cases from HCP during the 1988-1991 period were compared to cases reported from HCP in 1987, as well to the corresponding cases in the remaining hospitals of Barcelona. Between 1987 and 1988 there was a 245% increase in the reporting of Individualized Reportable Diseases and of 4345% for Numeric Reportable Diseases. The increased notification has also been shown for the most frequent Individualized Reportable Diseases: 364% for hepatitis, 195% for meningococcal infection and 233% for pulmonary tuberculosis. This system is an approach to the introduction, development and perfection of the detection process, in order to improve reporting levels in the hospital, contributing to strengthen the epidemiologic surveillance system in the community.

[Analysis and classification of hospital emergencies through Ambulatory Patient Groups]. / Análisis y clasificación de las urgencias hospitalarias mediante los Ambulatory Patient Groups.

AIM: To assess the feasibility and results of application of Ambulatory Patient Groups (APG) patient's classification system to the case-mix of patients seen at the Emergency Departments (ED) of 6 Barcelona metropolitan area hospitals. METHODS: Development of a minimum discharge data set specific for the Emergency Departments (CMBDAU). Gathering of relevant variables from a random sample of patients seen at the ED using the ED discharge reports. Use of the APG classification system to those episodes. RESULTS: A total of 11.188 episodes were codified and grouped with the APG system. Fifteen diagnostics identified 25% of all episodes. Nearly 50% of all procedures performed at the ED were common and simple procedures. Fifteen APG's grouped 50% of all cases seen at the ED. CONCLUSIONS: The ED Uniform Discharge Data Set (CMBDAU) developed is a valid instrument for describing the case-mix seen at the ED, and its grouping by means of the APG system provides consistent and meaningful results. The widespread use of systems like APG in the ED requires a former validation of relative weights assigned in the US system. The availability of human and technical resources must also be assessed, in order to guarantee the quality and sustainability of such a system.