Hand soap contamination by Pseudomonas aeruginosa in a tertiary care hospital: no evidence of impact on patients.

BACKGROUND: During an environmental investigation of Pseudomonas aeruginosa in intensive care units, the liquid hand soap was found to be highly contaminated (up to 8 × 10(5)cfu/g) with this pathogen. It had been used over the previous five months and was probably contaminated during manufacturing. AIM: To evaluate the burden of this contamination on patients by conducting an epidemiological investigation using molecular typing combined with whole genome sequencing (WGS). METHODS: P. aeruginosa isolates from clinical specimens were analysed by double locus sequence typing (DLST) and compared with isolates recovered from the soap. Medical charts of patients infected with a genotype identical to those found in the soap were reviewed. WGS was performed on soap and patient isolates sharing the same genotype. FINDINGS: P. aeruginosa isolates (N = 776) were available in 358/382 patients (93.7%). Only three patients (0.8%) were infected with a genotype found in the soap. Epidemiological investigations showed that the first patient was not exposed to the soap, the second could have been exposed, and the third was indeed exposed. WGS showed a high number of core single nucleotide polymorphism differences between patients and soap isolates. No close genetic association was observed between soap and patient isolates, ruling out the hypothesis of transmission. CONCLUSION: Despite a highly contaminated soap, the combined investigation with DLST and WGS ruled out any impact on patients. Hand hygiene performed with alcohol-based solution for >15 years was probably the main reason. However, such contamination represents a putative reservoir of pathogens that should be avoided in the hospital setting.

[Incident-reporting electronic-based system in internal medicine]. / Déclaration et traitement des événements indésirables en médecine interne.

How to recognize, announce and analyze incidents in internal medicine units is a daily challenge that is taught to all hospital staff. It allows suggesting useful improvements for patients, as well as for the medical department and the institution. Here is presented the assessment made in the CHUV internal medicine department one year after the beginning of the institutional procedure which promotes an open process regarding communication and risk management. The department of internal medicine underlines the importance of feedback to the reporters, ensures the staff of regular follow-up concerning the measures being taken and offers to external reporters such as general practioners the possibility of using this reporting system too.

Is trauma in Switzerland any different? epidemiology and patterns of injury in major trauma - a 5-year review from a Swiss trauma centre.

UNLABELLED: Switzerland, the country with the highest health expenditure per capita, is lacking data on trauma care and system planning. Recently, 12 trauma centres were designated to be reassessed through a future national trauma registry by 2015. Lausanne University Hospital launched the first Swiss trauma registry in 2008, which contains the largest database on trauma activity nationwide. METHODS: Prospective analysis of data from consecutively admitted shock room patients from 1 January 2008 to 31 December 2012. Shock room admission is based on physiology and mechanism of injury, assessed by prehospital physicians. Management follows a surgeon-led multidisciplinary approach. Injuries are coded by Association for the Advancement of Automotive Medicine (AAAM) certified coders. RESULTS: Over the 5 years, 1,599 trauma patients were admitted, predominantly males with a median age of 41.4 years and median injury severity score (ISS) of 13. Rate of ISS >15 was 42%. Principal mechanisms of injury were road traffic (40.4%) and falls (34.4%), with 91.5% blunt trauma. Principal patterns were brain (64.4%), chest (59.8%) and extremity/pelvic girdle (52.9%) injuries. Severe (abbreviated injury scale [AIS] score ≥ 3) orthopaedic injuries, defined as extremity and spine injuries together, accounted for 67.1%. Overall, 29.1% underwent immediate intervention, mainly by orthopaedics (27.3%), neurosurgeons (26.3 %) and visceral surgeons (13.9%); 43.8% underwent a surgical intervention within the first 24 hours and 59.1% during their hospitalisation. In-hospital mortality for patients with ISS >15 was 26.2%. CONCLUSION: This is the first 5-year report on trauma in Switzerland. Trauma workload was similar to other European countries. Despite high levels of healthcare, mortality exceeds published rates by >50%. Regardless of the importance of a multidisciplinary approach, trauma remains a surgical disease and needs dedicated surgical resources.

[Pathogen reduction of blood components: from financial issues to possible long-term consequences]. / Inactivation des pathogènes des produits sanguins labiles: entre enjeux financiers et conséquences possibles à long terme.

Pathogen inactivation of blood products represents a global and major paradigm shift in transfusion medicine. In the next near future, it is likely that most blood products will be inactivated by various physicochemical approaches. The concept of blood safety will be challenged as well as transfusion medicine practice, notably for donor selection or biological qualification. In this context, it seems mandatory to develop analytical economic approaches by assessing costs-benefits ratio of blood transfusion as well as to set up cohorts of patients based on hemovigilance networks allowing rigorous scientific analysis of the benefits and the risks of blood transfusion at short- and long-term.

[Early neurorehabilitation in an acute university hospital: from dream to reality]. / Neurorééducation précoce au Centre hospitalier universitaire vaudois: du rêve à la réalité.

The need for an early neurorehabilitation pathway was identified in an acute university hospital. A team was formed to draw up and implement it. A neuro-sensorial, interdisciplinary and coordinated therapy program was developed, focused on tracheostomised patients as soon as they were admitted to the intermediate care in neurology and neurosurgery. The impact of this care plan was evaluated by comparing the results obtained with that pertaining to patients treated previously in the same services. The comparison showed a reduction of 48% of the mean duration of tracheostomy, of 39% in the time to inscription in a neurorehabilitation centre and of 20% in the length of stay in the intermediate care. An early neurorehabilitation care program, with an interdisciplinary and coordinated team, reduces complications and lengths of stay.

Randomized controlled trial of peripherally inserted central catheters vs. peripheral catheters for middle duration in-hospital intravenous therapy.

INTRODUCTION: Intravenous (i.v.) therapy may be associated with important catheter-related morbidity and discomfort. The safety, efficacy, comfort, and cost-effectiveness of peripherally inserted central catheters (PICCs) were compared to peripheral catheters (PCs) in a randomized controlled trial. METHODS: Hospitalized patients requiring i.v. therapy >or= five days were randomized 1:1 to PICC or PC. Outcomes were incidence of major complications, minor complications, efficacy of catheters, patient satisfaction, and cost-effectiveness. RESULTS: 60 patients were included. Major complications were observed in 22.6% of patients in the PICC group [six deep venous thrombosis (DVT), one insertion-site infection] and 3.4% of patients in the PC group [one DVT; risk ratio (RR) 6.6; P = 0.03]. Superficial venous thrombosis (SVT) occurred in 29.0% of patients in the PICC group and 37.9% of patients in the PC group (RR 0.60; P = 0.20). Patients in the PICC group required 1.16 catheters on average during the study period, compared with 1.97 in the PC group (P < 0.04). The mean number of venipunctures (catheter insertion and blood sampling) was 1.36 in the PICC group vs. 8.25 in the PC group (P < 0.001). Intravenous drug administration was considered very or quite satisfying by 96.8% of the patients in the PICC group, and 79.3% in the PC group. Insertion and maintenance mean cost was 690 US$ for PICC and 237 US$ for PC. DISCUSSION: PICC is efficient and satisfying for hospitalized patients requiring i.v. therapy >or= five days. However, the risk of DVT, mostly asymptomatic, appears higher than previously reported, and should be considered before using a PICC.

[Physician-assisted suicide in university hospital: are we ready?]. / Assistance au suicide en hôpital de soins aigus: sommes-nous prêts?

Assisting people to commit suicide has generated a passionate public debate. In exceptional situations, access to this support can be granted to the demanders in a hospital environment. So did the CHUV and the academic hospitals of Geneva draw up a procedure permitting, in principle, the access to an assistance to commit suicide. Two recent clinical situations experienced in the CHUV's Service of internal medicine have created a lot of discussions, doubts and revealed, sometimes, divergent positions. By the light of this clinical cases, we wished to share the perspective of the internist in charge of the ethician, of the chaplain, of the medical director, of the psychiatrist and of the palliative care responsible. Theses complex situations illustrate the deep ambivalence felt by the clinicians confronted to situations which require a multidisciplinary approach.

[Defining interfaces to improve quality of care: the example of anorexia nervosa in acute somatic hospitalisation]. / La définition des interfaces pour améliorer la qualité: l'exemple de l'anorexie en hospitalisation somatique.

Specialisation in medicine requires multidisciplinary approaches, and hence coordination in collaborations of the different partners involved. These integrated approaches, sometimes called "disease management", fit particularly well to chronic diseases. Our institution introduced an integrated approach for taking care of the acute somatic hospitalisation of patients suffering from anorexia nervosa. Interfaces with the different partners were defined, specifying tasks, rights, and duties of each person, care givers or patients. This initiative allows now to identify any deviation occurring in the process of care or hole in the care system, so that it can be corrected and recurrence prevented. This model will be extended to other complex and multidisciplinary care processes and other services in our institution.

[Generic drug prescribing: pilot study on the impact of the new drug pricing system on costs and potential savings]. / Prescription de médicaments génériques: impact du nouveau système de prix sur les coûts et les économies potentielles.

The impact of a systematic generic substitution and of the new drug pricing system (implemented in 2002 for cost saving reasons) on prescription cost was computed on the basis of prescriptions delivered in January 1999 for patients leaving our university hospital. A total of 3,099 prescriptions, representing 5,514 drugs, were delivered in one month, of which 335 (6%) were excluded (drug not available in 2002 or magistral preparations). Forced generic prescription would have saved 3,8% of global costs, while the new drug pricing system would have increased costs between 1,1% and 8,0%. In this specific setting, savings linked with forced generic drug prescription was weak (4 to 5%), and the expected savings of the new drug pricing system were not observed.

[Merging of two intensive care units: preliminary observations]. / Fusion de deux services de médecine intensive: quelques observations préliminaires.

The merging of two intensive care units is a time of profound change, and constitutes a risk of mishaps. We report some aspects of such a project in our institution. The evaluation of various indicators reflecting the activity, patient's hospital pathways, mortality, as well as the use of specific techniques, has shown that no particular problem was observed during the first 9 months. Improvements in performance or productivity have not been demonstrated so far. The follow-up will permit to demonstrate long-term benefits. We believe that these observations may be of interest for other departmental or hospital reorganisations.

Is early endoscopy in the emergency room beneficial in patients with bleeding peptic ulcer? A "fortuitously controlled" study.

BACKGROUND AND STUDY AIMS: In previous randomized trials, early endoscopy improved the outcome in patients with bleeding peptic ulcer, though most of these studies defined "early" as endoscopy performed within 24 hours after admission. Using the length of hospital stay as the primary criterion for the clinical outcome, we compared the results of endoscopy done immediately after admission (early endoscopy in the emergency room, EEE) with endoscopy postponed to a time within the first 24 hours after hospitalization, but still during normal working hours ("delayed" endoscopy in the endoscopy unit, DEU). PATIENTS AND METHODS: We conducted a retrospective analysis of data from 81 consecutive patients with bleeding peptic ulcer admitted in 1997 and 1998 (age range 16 - 90 years). Of these 81 patients, 38 underwent DEU (the standard therapy at the hospital) and 43 underwent EEE. Patients in the two groups were comparable with regard to admission criteria, were equally distributed with respect to their risk of adverse outcome (assessed using the Baylor bleeding score and the Rockall score), and differed only in the treatment they received. Endoscopic hemostasis was performed whenever possible in all patients with Forrest types I, IIa, and IIb ulcer bleeding. RESULTS: We found similar rates in the two groups for recurrent bleeding (16 % in DEU patients vs. 14 % in EEE patients), persistent bleeding (8 % in DEU patients vs. none in EEE patients), medical complications (21 % in DEU patients vs. 26 % in EEE patients), the need for surgery (8 % in DEU patients vs. 9 % in EEE patients), and the length of hospital stay (5.1 days for DEU patients vs. 5.9 days for EEE patients). None of the differences between the two groups in these parameters were statistically significant. None of the patients died. CONCLUSIONS: Early endoscopy in an emergency room did not improve the clinical outcome in our 81 consecutive patients with bleeding peptic ulcer.

Cost-effectiveness of full-course oral levofloxacin in severe community-acquired pneumonia.

Oral levofloxacin is as efficient as sequential antibiotic treatment in community-acquired pneumonia (CAP). The current authors assessed whether oral levofloxacin treatment of patients with severe CAP, followed-up for 30 days, would save money. Over a 12-month period, 129 hospitalised patients with severe non-intensive care unit CAP were randomly assigned to receive either oral levofloxacin or sequential antibiotic treatment. Direct and indirect costs were compared over a 30-day period from several perspectives. CAP resolved in 71 out of 77 oral levofloxacin (92%) and in 34 out of 37 sequential antibiotic treatment patients (92%). Patients' characteristics, treatment duration, hospital length of stay and mortality were similar in both groups. Drug acquisition costs were 1.7-times smaller in oral levofloxacin patients, who were less often transferred to rehabilitation centres, but they used more physicians' visits during follow-up and their total costs were lower. As only a minority of patients was still active, inability to work and, hence, indirect costs were similar in both groups. In this study, oral levofloxacin for severe non-intensive care unit community-acquired pneumonia was equally effective as sequential antibiotic treatment, but did not lead to major costs savings except for drug acquisition costs. External factors linked with patients' characteristics and/or medical practice are likely to play a role and should be addressed.

Minimally invasive fixation versus conservative treatment of undisplaced scaphoid fractures: a cost-effectiveness study.

This study compares the direct and indirect costs of conservative and minimally invasive treatment for undisplaced scaphoid fractures. Costs data concerning groups of non-operated and operated patients were analysed. Direct costs were higher in operated patients. Although highly variable, indirect costs were significantly smaller in operated patients and the total costs were higher in non-operated patients. In conclusion, operative treatment of scaphoid fractures is initially more expensive than conservative treatment but markedly decreases the work compensation costs.

Three years of haemovigilance in a general university hospital.

The aim of this study is to describe a newly implemented haemovigilance system in a general university hospital. We present a series of short cases, highlighting particular aspects of the reports, and an overview of all reported incidents between 1999 and 2001. Incidents related to transfusion of blood products were reported by the clinicians using a standard preformatted form, giving a synopsis of the incident. After analysis, we distinguished, on the one hand, transfusion reactions, that are transfusions which engendered signs or symptoms, and, on the other hand, the incidents where management errors and/or dysfunctions took place. Over 3 years, 233 incidents were reported, corresponding to 4.2 events for 1000 blood products delivered. Of the 233, 198 (85%) were acute transfusion reactions and 35 (15%) were management errors and/or dysfunctions. Platelet units gave rise to statistically (P < 0.001) more transfusion reactions (10.7 per thousand ) than red blood cells (3.5 per thousand ) and fresh frozen plasma (0.8 per thousand ), particularly febrile nonhaemolytic transfusion reactions and allergic reactions. A detailed analysis of some of the transfusion incident reports revealed complex deviations and/or failures of the procedures in place in the hospital, allowing the implementation of corrective and preventive measures. Thus, the haemovigilance system in place in the 'Centre Hospitalier Universitaire Vaudois, CHUV' appears to constitute an excellent instrument for monitoring the security of blood transfusion.

Rate, type, and cost of adverse drug reactions in emergency department admissions.

Background: Adverse drug reactions (ADRs) are a threat to patients' health and quality of life, and can generate significant expenses. They are generally underreported, with different rates in different health care systems. Methods: We conducted a 6-month survey of all primary admissions to the medical emergency department of a university hospital and assessed the rate, characteristics, avoidability, and marginal costs of ADRs. Results: A total of 7% of all admissions were mainly caused by ADRs. The most frequent were gastrointestinal bleeding (22.3%) and febrile neutropenia (14.4%). Anticancer drugs were involved in 22.7% of the cases, and anticoagulants, analgesics, and non-steroidal anti-inflammatory drugs in 8% each. Physicians had prescribed 70% of these drugs. Patients were predominantly treated in intermediate care units and ordinary wards. The mean cost per case amounted to CHF 3586+/-342, or a total of CHF 821204 over the 6-month-period (1 CHF=0.56 US$=0.87 Euro). A total of 67% were considered definitely imputable to drug effects and 32% were retrospectively regarded as avoidable. Conclusions: Interventions aimed at reducing the incidence of ADRs should be directed towards both patient education and physician training. This could save hospitals admissions and money, and could be used as an indicator of prescription quality.

[Medical-economic analysis: a necessary complement to "evidence based medicine"]. / Les analyses médico-économiques: un complément nécessaire à "evidence based medicine".

After an extraordinary technical development, medicine is under close scrutiny and requested to prove that its diagnostic and therapeutic procedures are "efficient, appropriate, and economical". Evidence based medicine allows the optimal use of existing data in the literature, but focuses only on health care benefits. Economical analyses take into account the health care resources needed to get these benefits. The various types of costs, perspectives of analysis, and techniques for assessing benefits and uncertainty about cost estimates, are presented and illustrated with two examples drawn from the fields of primary care and advanced technology. Because the cost benefit ratio of a diagnostic or therapeutic procedure is heavily dependent on the type of patients to which it is applied, as well as on the stage of technological progress, the two types of information are necessary to fully assess medical procedures.

Human errors in a multidisciplinary intensive care unit: a 1-year prospective study.

OBJECTIVES: To determine the incidence and identify risk factors of critical incidents in an ICU. DESIGN: Prospective observational study of consecutive patients admitted over 1 year to an ICU. Critical incidents were recorded using predefined criteria. Their causes and consequences were analysed. The causes were classified as technical failure, patient's underlying disease, or human errors (subclassified as planning, execution, or surveillance). The consequences were classified as lethal, leading to sequelae, prolonging the ICU stay, minor, or without consequences. The correlation between critical incidents and specific factors including patient's diagnosis and severity score, use of monitoring and therapeutic modalities was analysed by uni- and multivariate analysis. SETTING: An 11-bed multidisciplinary ICU in a non-university teaching hospital. PATIENTS: 1,024 consecutive patients admitted to the ICU. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The median length of ICU stay by the 1,024 patients was 1.9 days. Of the 777 critical incidents reported 2% were due to technical failure and 67 % to secondary to underlying disease. There were 241 human errors (31%) in 161 patients, evenly distributed among planning (n = 75), execution (n = 88), and surveillance (n = 78). One error was lethal, two led to sequelae, 26 % prolonged ICU stay, and 57 % were minor and 16 % without consequence. Errors with significant consequences were related mainly to planning. Human errors prolonged ICU stay by 425 patient-days, amounting to 15 % of ICU time. Readmitted patients had more frequent and more severe critical incidents than primarily admitted patients. CONCLUSIONS: Critical incidents add morbidity, workload, and financial burden. A substantial proportion of them are related to human factors with dire consequences. Efforts must focus on timely, appropriate care to avoid planning and execution mishaps at the beginning of the ICU stay; surveillance intensity must be maintained, specially after the fourth day.