Implementación de un código de trauma en un servicio de emergencias de un hospital nacional / Implementation of a trauma code

Resumen Objetivo: Desarrollar una propuesta accesible a la realidad local de un hospital general terciario (Hospital Calderón Guardia) para la implementación de un código de trauma, basada en la mejor evidencia médico científica disponible. Métodos: Se realizó una revisión de la bibliografía; se buscaron los trabajos de investigación publicados a nivel nacional e internacional sobre la conformación y criterios relativos al código de trauma, su implementación, sus desafíos, y sus limitaciones; mediante 3 buscadores: Scielo, Pubmed y Ovid. Se incluyeron estudios con diversa metodología, disponibles en inglés o español. Resultados: Treinta artículos publicados en revistas indexadas fueron seleccionados y la información se agrupó en las siguientes categorías: Conformación del equipo de trauma en la activación de los códigos para cada hospital, criterios de activación, niveles de activación, experiencia local y limitaciones. Dicha información permitió identificar dos elementos principales para conseguir un beneficio: la conformación de un equipo multidisciplinario de primera respuesta para los pacientes más graves y la estandarización de criterios específicos para la activación de dicho equipo; entonces, se procedió a elaborar y proponer un modelo viable y concordante con las características del servicio hospitalario. Conclusión: La implementación hospitalaria de un modelo de código de trauma supone un impacto positivo en los desenlaces de morbi-mortalidad, a través de dos 2 mecanismo principales: la conformación de un equipo multidisciplinario de primera respuesta para los pacientes más graves y la estandarización de criterios específicos para la activación de dicho equipo; por lo que se elaboró un modelo ajustado a las necesidades y recursos del hospital.

Abstract Objective: To develop a proposal of a trauma code accessible to the local characteristics of a tertiary general hospital (Hospital Calderón Guardia) based on the best clinical evidence available. Methods: A literary search was made of national and international scientific papers regarding several aspects about trauma code, it´s implementation, it´s challenges, main benefits, and it´s limitations in 3 main web search portals: Scielo, PubMed and Ovid. We included paper studies in English and Spanish. Results: Thirty scientific papers from index journals were selected for review and the following data were extracted: Trauma team conformation, trauma team activation criteria, levels for trauma team activation, local experience, and limitations. That information allowed us to identify 2 main beneficial elements: the conformation of the trauma team and the standardization of the specific criteria necessary for its activation. Also, we elaborated a proposal for a viable model in accordance with our resources. Conclusion: According to scientific review, trauma code implementation in any institution associates a positive impact in clinical patient outcomes through 2 main mechanisms: the conformation of a multidisciplinary trauma team response of severe trauma patients, and the standardization of criteria for activation of the trauma teams. With these findings we elaborated a proposal adjusted to the needs and resources of Hospital Rafael Angel Calderon Guardia.

Descriptive survey of women's childbirth experiences in two state hospitals in KwaZulu-Natal.

BACKGROUND: Giving birth is one of the most important events in a woman's life and is a highly individualistic and unique experience. OBJECTIVES: The study aimed to describe women's childbirth experiences in two state hospitals in KwaZulu-Natal. METHOD: A non-experimental, quantitative, descriptive survey of low-risk mothers was conducted in two state hospitals by using the Childbirth Experience Questionnaire (CEQ). RESULTS: With a response rate of 96%, 201 questionnaires were completed and returned. The highest mean score of the four dimensions of the CEQ was for the dimension of Professional Support (3.1). The results of the individual dimension items scoring the highest positive response were: I felt that I handled the situation well (147; 74%) (Own Capacity); I felt very well cared for by my midwife (165; 82%) (Professional Support); 151 respondents (76%) scored the item My impression of the team's medical skill made me feel secure as the highest positive experience (Perceived Safety); and I felt I could have a say in the choice of pain relief (105; 52%) (Participation). The relationship between demographic variables (age, level of education, parity, antenatal clinic attendance, induction of labour, augmentation and duration of labour) and respondents' scores of the CEQ dimensions was calculated, and only the dimension of Perceived Safety and duration of labour (≥ 12 hours) were found to be significant (p = 0.026). CONCLUSION: From the women perspectives, the study results described childbirth experience as multi-dimensional experience and subjective. Both positive and negative experiences coexisted in all dimensions of the CEQ, with the dimension of Professional Support scoring the highest positive response. To maintain a positive birth experience, the study suggests that women should be involved and equipped with knowledge on the process of childbirth.

Do performance indicators predict regulator ratings of healthcare providers? Cross-sectional study of acute hospitals in England.

OBJECTIVE: To determine whether a large set of care performance indicators ('Intelligent Monitoring (IM)') can be used to predict the Care Quality Commission's (CQC) acute hospital trust provider ratings. DESIGN: The IM dataset and first-inspection ratings were used to build linear and ordered logistic regression models for the whole dataset (all trusts). This was repeated for subsets of the trusts, with these models then applied to predict the inspection ratings of the remaining trusts. SETTING: The United Kingdom Department of Health and Social Care's Care Quality Commission is the regulator for all health and social care services in England. We consider their first-inspection cycle of acute hospital trusts (2013-2016). PARTICIPANTS: All 156 English NHS acute hospital trusts. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Percentage of correct predictions and weighted kappa. RESULTS: Only 24% of the predicted overall ratings for the test sample were correct and the weighted kappa of 0.01 indicates very poor agreement between predicted and actual ratings. This lack of predictive power is also found for each of the rating domains. CONCLUSION: While hospital inspections draw on a much wider set of information, the poor power of performance indicators to predict subsequent inspection ratings may call into question the validity of indicators, ratings or both. We conclude that a number of changes to the way performance indicators are collected and used could improve their predictive value, and suggest that assessing predictive power should be undertaken prospectively when the sets of indicators are being designed and selected by regulators.

Getting It Right First Time: the national survey of surgical site infection rates in NHS trusts in England.

INTRODUCTION: Surgical site infections are associated with increased morbidity and mortality in patients. The Getting It Right First Time surgical site infection programme set up a national survey to review surgical site infection rates in surgical units in England. The objectives were for frontline clinicians to assess the rates of infection following selected procedures, to examine the risk of significant complications and to review current practice in the prevention of surgical site infection. METHODS: A national survey was launched in April 2017 to assess surgical site infections within 13 specialties: breast surgery, cardiothoracic surgery, cranial neurosurgery, ear, nose and throat surgery, general surgery, obstetrics and gynaecology, ophthalmology, oral and maxillofacial surgery, orthopaedic surgery, paediatric surgery, spinal surgery, urology and vascular surgery. All participating trusts prospectively identified and collected supporting information on surgical site infections diagnosed within the six-month study period. RESULTS: Data were received from 95 NHS trusts. A total of 1807 surgical site infection cases were reported. There were variations in rates reported by trusts across specialties and procedures. Reoperations were reported in 36.2% of all identified cases, and surgical site infections are associated with a delayed discharge rate of 34.1% in our survey. CONCLUSION: The Getting It Right First Time surgical site infection programme has introduced a different approach to infection surveillance in England. Results of the survey has demonstrated variation in surgical site infection rates among surgical units, raised the importance in addressing these issues for better patient outcomes and to reduce the financial burden on the NHS. Much work remains to be done to improve surgical site infection surveillance across surgical units and trusts in England.

Cultura de segurança do paciente em três hospitais brasileiros com diferentes tipos de gestão / Patient safety culture in three Brazilian hospitals with different types of management

Resumo O objetivo do estudo foi avaliar a cultura de segurança do paciente e fatores associados em hospitais brasileiros com diferentes tipos de gestão: federal, estadual e privado. O desenho foi observacional transversal. Enviaram-se 1576 questionários aos profissionais de três hospitais do estado do Rio Grande do Norte, utilizando o Hospital Survey on Patient Safety Culture, adaptado para o Brasil, que mede 12 dimensões da cultura de segurança. As percepções são descritas através de uma nota geral (0 a 10) e dos percentuais de respostas positivas para estimar fortalezas e fragilidades em cada dimensão. A taxa de resposta foi de13,6% (n = 215). A segurança do paciente teve nota entre 7 e 10, para 78,1% dos respondentes, sendo a maior média das notas apresentada pelo hospital privado (8,32). O tipo de gestão hospitalar, unidade de serviço, cargo e quantidade de notificação de eventos adversos estiveram associados à nota geral da segurança do paciente (p < 0,001). Apenas o hospital privado apresentou fortalezas nas dimensões analisadas, enquanto que as fragilidades apareceram em todos os hospitais.

Abstract The scope of the study was to evaluate patient safety culture and associated factors in Brazilian hospitals with different types of management, namely federal, state and private hospitals. The design was cross-sectional and observational. A survey of 1576 professionals at three hospitals of Rio Grande do Norte state was performed using the Hospital Survey on Patient Safety Culture adapted for Brazil, which measures 12 dimensions of safety culture. Perceptions are described by attributing a general result (Range 0-10) and the percentage of positive responses to estimate their strengths and weaknesses. The response rate was 13.6% (n= 215). The patient safety coefficient was between 7 and 10 for 78.1% of the respondents, whereby the highest average grade was attributed to the private hospital (8.32). It has been estimated that the type of hospital management, unit service, position and number of adverse event notifications are associated with the overall patient safety grade (p <0.001). Only the private hospital had strengths in the dimensions analyzed, while the weaknesses appeared in all the hospitals.

[Patient safety culture in three Brazilian hospitals with different types of management]. / Cultura de segurança do paciente em três hospitais brasileiros com diferentes tipos de gestão.

The scope of the study was to evaluate patient safety culture and associated factors in Brazilian hospitals with different types of management, namely federal, state and private hospitals. The design was cross-sectional and observational. A survey of 1576 professionals at three hospitals of Rio Grande do Norte state was performed using the Hospital Survey on Patient Safety Culture adapted for Brazil, which measures 12 dimensions of safety culture. Perceptions are described by attributing a general result (Range 0-10) and the percentage of positive responses to estimate their strengths and weaknesses. The response rate was 13.6% (n= 215). The patient safety coefficient was between 7 and 10 for 78.1% of the respondents, whereby the highest average grade was attributed to the private hospital (8.32). It has been estimated that the type of hospital management, unit service, position and number of adverse event notifications are associated with the overall patient safety grade (p <0.001). Only the private hospital had strengths in the dimensions analyzed, while the weaknesses appeared in all the hospitals.

O objetivo do estudo foi avaliar a cultura de segurança do paciente e fatores associados em hospitais brasileiros com diferentes tipos de gestão: federal, estadual e privado. O desenho foi observacional transversal. Enviaram-se 1576 questionários aos profissionais de três hospitais do estado do Rio Grande do Norte, utilizando o Hospital Survey on Patient Safety Culture, adaptado para o Brasil, que mede 12 dimensões da cultura de segurança. As percepções são descritas através de uma nota geral (0 a 10) e dos percentuais de respostas positivas para estimar fortalezas e fragilidades em cada dimensão. A taxa de resposta foi de13,6% (n = 215). A segurança do paciente teve nota entre 7 e 10, para 78,1% dos respondentes, sendo a maior média das notas apresentada pelo hospital privado (8,32). O tipo de gestão hospitalar, unidade de serviço, cargo e quantidade de notificação de eventos adversos estiveram associados à nota geral da segurança do paciente (p < 0,001). Apenas o hospital privado apresentou fortalezas nas dimensões analisadas, enquanto que as fragilidades apareceram em todos os hospitais.

Differences in Acute Ischemic Stroke Quality of Care and Outcomes by Primary Stroke Center Certification Organization.

BACKGROUND AND PURPOSE: Primary stroke center (PSC) certification was established to identify hospitals providing evidence-based care for stroke patients. The numbers of PSCs certified by Joint Commission (JC), Healthcare Facilities Accreditation Program, Det Norske Veritas, and State-based agencies have significantly increased in the past decade. This study aimed to evaluate whether PSCs certified by different organizations have similar quality of care and in-hospital outcomes. METHODS: The study population consisted of acute ischemic stroke patients who were admitted to PSCs participating in Get With The Guidelines-Stroke between January 1, 2010, and December 31, 2012. Measures of care quality and outcomes were compared among the 4 different PSC certifications. RESULTS: A total of 477 297 acute ischemic stroke admissions were identified from 977 certified PSCs (73.8% JC, 3.7% Det Norske Veritas, 1.2% Healthcare Facilities Accreditation Program, and 21.3% State-based). Composite care quality was generally similar among the 4 groups of hospitals, although State-based PSCs underperformed JC PSCs in a few key measures, including intravenous tissue-type plasminogen activator use. The rates of tissue-type plasminogen activator use were higher in JC and Det Norske Veritas (9.0% and 9.8%) and lower in State and Healthcare Facilities Accreditation Program certified hospitals (7.1% and 5.9%) (P<0.0001). Door-to-needle times were significantly longer in Healthcare Facilities Accreditation Program hospitals. State PSCs had higher in-hospital risk-adjusted mortality (odds ratio 1.23, 95% confidence intervals 1.07-1.41) compared with JC PSCs. CONCLUSIONS: Among Get With The Guidelines-Stroke hospitals with PSC certification, acute ischemic stroke quality of care and outcomes may differ according to which organization provided certification. These findings may have important implications for further improving systems of care.

Smoking cessation care in state-operated or state-supported psychiatric hospitals: from policy to practice.

OBJECTIVES: The aims of this study were to identify changes in smoking policies and their implementation and to determine the level of smoking cessation care provided at state-operated or state-supported psychiatric inpatient hospitals. METHODS: Hospitals were surveyed in 2008 (N=219) and 2011 (N=206) about their smoking policies and practices, and changes in specific policies and practices, such as staff specialty training about smoking cessation care, assessment at intake, provision of smoking cessation treatment and education, and aftercare planning, were examined. Smoking cessation care was categorized as best, good, average, or poor. RESULTS: The survey was completed in both 2008 and 2011 by 108 hospitals. The number of hospitals prohibiting smoking rose by 73%, from 48% in 2008 to 83% in 2011. The provision of specialty training to staff did not significantly improve. Nearly all hospitals assessed smoking status at admission, and nicotine replacement therapy was provided by more hospitals than any other treatment in both 2008 and 2011. The number of hospitals providing no follow-up of smoking cessation care after discharge dropped significantly, from 64% to 41%, and significantly more provided good versus average smoking cessation care. CONCLUSIONS: Analysis of smoking policies at state-operated or state-supported psychiatric inpatient hospitals found significant movement in adopting nonsmoking policies and some increase in active treatment, notably wellness counseling. Educational resources have not reached full penetration, and continuum of care activities are also lagging behind. Additional resources and staff training may be needed to continue to address smoking cessation both during and after hospitalization.

Using structured clinical feedback to encourage alternatives to use of "P.R.N." medication in a state psychiatric hospital.

OBJECTIVE: The study examined whether reductions in the use of pro re nata (p.r.n.) psychotropic medications could be achieved in a large public-sector psychiatric hospital, without adverse behavioral consequences, by disseminating a database that tracks p.r.n. use to clinical teams. METHODS: A performance improvement project was implemented over 28 months, involving all 166 patients in one section of a state psychiatric hospital. A spread- sheet tracking p.r.n. administration for each patient was provided weekly to unit treatment teams. Clinical outcome monitoring focused on the number of p.r.n. administrations and on p.r.n. "events," defined as ≥ 3 multiple administrations per week and ≥ 10 per month. Episodes of patient seclusion, restraint, and violent incidents were also monitored. RESULTS: From September 2008 to December 2010, with a stable patient population census, total monthly administrations of psychotropic p.r.n. medications decreased from 642 to 240; administrations of non-psychotropic "medical" p.r.n. agents also decreased, from 279 to 72. In year-by-year comparisons, significant decreases (P < 0.05) were observed in the total number of psychotropic and medical p.r.n. administrations, in weekly as well as monthly p.r.n. events, and in the number of patients receiving any p.r.n. administrations. There was no change from 2008 to 2010 in the number of violent incidents; the use of both seclusion and restraint decreased (P < 0.05). CONCLUSION: The findings suggest that p.r.n. use can be reduced safely through timely feedback of relevant clinical data.

Use of administrative data in efficient auditing of hospital-acquired surgical site infections, New York State 2009-2010.

OBJECTIVE: To efficiently validate the accuracy of surgical site infection (SSI) data reported to the National Healthcare Safety Network (NHSN) by New York State (NYS) hospitals. DESIGN: Validation study. SETTING: 176 NYS hospitals. METHODS: NYS Department of Health staff validated the data reported to NHSN by review of a stratified sample of medical records from each hospital. The four strata were (1) SSIs reported to NHSN; (2) records with an indication of infection from diagnosis codes in administrative data but not reported to NHSN as SSIs; (3) records with discordant procedure codes in NHSN and state data sets; (4) records not in the other three strata. RESULTS: A total of 7,059 surgical charts (6% of the procedures reported by hospitals) were reviewed. In stratum 1, 7% of reported SSIs did not meet the criteria for inclusion in NHSN and were subsequently removed. In stratum 2, 24% of records indicated missed SSIs not reported to NHSN, whereas in strata 3 and 4, only 1% of records indicated missed SSIs; these SSIs were subsequently added to NHSN. Also, in stratum 3, 75% of records were not coded for the correct NHSN procedure. Errors were highest for colon data; the NYS colon SSI rate increased by 7.5% as a result of hospital audits. CONCLUSIONS: Audits are vital for ensuring the accuracy of hospital-acquired infection (HAI) data so that hospital HAI rates can be fairly compared. Use of administrative data increased the efficiency of identifying problems in hospitals' SSI surveillance that caused SSIs to be unreported and caused errors in denominator data.

Causality analysis on health care evaluation criteria for state-operated mental hospitals in Korea using Malcolm Baldrige National Quality Award model.

Hospitals today are pressured to move away from the conventional health services management techniques and provide higher-quality health care to survive in intense competition. In our study, we aimed to develop health care evaluation criteria for the mental health care sector based on the existing Malcolm Baldrige National Quality Award model, and verify the causality of the evaluation model to lay groundwork for future research on the outcomes of national quality awards for mental health care. We focused on comparison groups comprising five state-operated mental hospitals in Korea using 92 survey questions derived from the MBNQA criteria for health care through structural equation modeling techniques. We verified that Leadership drives Foundation and Direction, which affect System that creates Results with 15 hypotheses supported out of 18 hypotheses established. We believe our findings will provide valuable implications to the top management of mental hospitals for self-examining quality management and promoting competitiveness.

[Benchmarking in psychiatric acute care--a demonstration project in a hospitals network]. / Benchmarking in der psychiatrischen Akutbehandlung - Ein Modellprojekt im Klinikverbund.

The aim of this project was to improve treatment processes and results in acutely ill inpatients within a network of nine psychiatric state hospitals of the Landschaftsverband Rheinland by introducing a benchmarking process. The project was based upon pre-existing measures of quality management. Patient groups were selected that were characterised by a severe clinical development or a high demand for mental health care services (alcohol abuse, depression of the elderly, schizophrenia). Room for improvement concerning specific hospitals and the overall hospital network were identified. The project was conducted with two patient cohorts before and after a quality-related intervention. Interventions were implemented for specific hospitals and the overall hospital network. Overall treatment documentations of 1,696 patients (1(st) cohort n=1,856, 2(nd) cohort n=1,696) were completed. Although there was no constant quantifiable statistically significant improvement of quality within the three patient groups (and certainly not with respect to the overall network), there was successful improvement of essential treatment processes for certain hospitals and the overall network under benchmarking. This was especially relevant where treatment recommendations were concerned. Future projects should focus on the conformance with treatment guidelines by defining both structural and process measures as a starting point and evaluation criterion.

[Assessment of targeted clinical audit in suicide attempt]. / Prise en charge des suicidants. Quel apport d'une démarche d'audit clinique ciblé?

BACKGROUND: Suicide attempt is a serious condition that is frequent in France. Picardie ranks fifth in France for suicide (418 deaths in 2005 for 1,890,000 inhabitants). Suicide attempt is one of the priorities of the regional public health program. The National Agency for Accreditation and Evaluation in Health (Anaes) has designed targeted clinical audits (TCA) on various conditions to promote this method as the basic tool for quality improvement. AIM: We investigated the contribution of TCA for improving the quality of care of suicide attempt within a regional framework in Picardie. METHODS: TCA were conducted in 12 state hospitals (eight Surgical Medicine and Obstetrics, three specialized in psychiatry, one local) between 2004 and 2006. The standards from the Anaes had 16 criteria in three fields: care on admission (n=10); assessment of family and social environment (n=2); management for after hospital care (n=4). A project manager and a MD certified in health care quality supported the medical (MD certified in acute care and in psychiatry) and nursing staff of the emergency wards. All the wards analyzed 30 patients' files for the first cycle, set up and implemented improvement actions and then performed the second cycle of data collection. RESULTS: All wards fully satisfied the protocol with 30 patients' files per cycle and two cycles. In all wards the teams consisted of physicians (both certified for emergency or psychiatry) and others care providers (nurses, psychologists, social workers, secretary). For the first cycle, three criteria (patient assessment, somatic examination and coordination) met the 100% target for more than half of the wards while three criteria (sociofamily and environmental evaluation, management for after hospital care, monitoring of follow-up) did not conform by more than 50% in more than half of the wards. All wards implemented changes after the first cycle with a total of 29 interventions, each one specifically devoted to improving a particular criterion. Intervention included better coordination and communication, protocol design and reminders, and information tools. The second cycle showed modest and mixed changes. After the interventions only one criteria reached the 100% target in one ward; the degree of conformity decreased in nine cases (with a mean of -23%) and increased in 16 cases (+19%). Globally, three criteria improved by less than 10% while three slightly decreased. DISCUSSION: G. Shaw introduced clinical audits in 1989 to boost a poorly performing system within the "clinical governance" framework, a condition quite different from the French healthcare system in 2005. Therefore, the validation of clinical audit in a different context appeared necessary. Anaes has not yet published the evaluation of this method in a peer reviewed journal. Observed changes are modest and mixed. Moreover, the true impact on care delivery appears limited and one cannot rule out that the observed improvements are in fact related to an improvement in traceability or due to Hawthorne's effect. Quality improvement methods must be evaluated and validated by scientific methods such as for new treatments with clinical research. CONCLUSION: The feasibility of the method was excellent, due to the methodological and technical support, however the method did not significantly improve the quality of care.

Measuring shared inefficiency between hospital cost centers.

In this article, a combination of data envelopment analysis, spreadsheet modeling and regression techniques is applied to a panel of nonprofit Washington State hospitals in an effort to determine whether (and if so, to what extent) inefficiency in one hospital cost center is shared with inefficiency in other cost centers. The findings suggest that a significant amount of inefficiency is shared across hospital cost centers. The authors further determine that certain cost centers contribute more to the overall performance of a given hospital than others. As such, managerial decisions and government policies designed to enhance hospital efficiency should be implemented differently, depending on the characteristics of the hospital in question.

Scaling up community-based services and improving quality of care in the state psychiatric hospitals: the way forward for Ghana.

OBJECTIVE: This paper aims to explore the options available for developing community-based care and improving the quality of care in psychiatric hospitals in Ghana. METHOD: Semi-structured interviews (SSIs) and focus group discussions (FGDs) were conducted: with a cross-section of stakeholders including health professionals, researchers, policy makers, politicians, users and carers. The SSIs and FGDs were recorded digitally and transcribed verbatim. Apriori and emergent themes were coded and analysed with NVivo version 7.0, using a framework analysis. RESULTS: Psychiatric hospitals in Ghana have a mean bed occupancy rate of 155%. Most respondents were of the view that the state psychiatric hospitals were very congested, substantially compromising quality of care. They also noted that the community psychiatric system was lacking human and material resources. Suggestions for addressing these difficulties included committing adequate resources to community psychiatric services, using psychiatric hospitals only as referral facilities, relapse prevention programmes, strengthening psychosocial services, adopting more precise diagnoses and the development of a policy on long-stay patients. CONCLUSION: There is an urgent need to build a credible system of community-based care and improve the quality of care in psychiatric hospitals in Ghana.

Achieving quality in a government hospital: departmental responsibility.

Quality improvement in health care organizations requires structural reorganization and system reform and the development of an appropriate organizational "culture." In 2007, the Division of Quality and Excellence in Civil Service in Israel developed a concept to improve quality management in governmental institutions throughout the country. To put this strategy into practice, Western Galilee Hospital, a governmental hospital, in northern Israel, developed a plan to advance the quality management system where each department and unit is autonomously responsible for its own quality and excellence. Since the hospital has been certificated by ISO 9001 for more than 10 years (the only hospital in Israel to have this certificate), the main challenge now is to improve the quality and excellence system in every department. The aim of this article is to describe the implementation of a comprehensive program designed to raise the ability of managers and workers in Western Galilee Hospital in addressing all of the government's requirements for quality and excellence in service in Israel.

Providing medical care in state psychiatric hospitals.

BACKGROUND: Dorothea Dix State Psychiatric Hospital (DDH) was cited by regulatory agencies in 1999-2001 for serious deficiencies in providing medical care to psychiatric patients. This resulted in a change in the discipline responsible for providing medical care. We report here how clinical staff and regulatory agencies evaluated the change. In addition, we sought to determine how medical care is currently provided at other state hospital across the nation. METHODS: A transition occurred whereby the responsibility for medical care (direct care and supervision of physician extenders) was changed from psychiatrists to internists. We surveyed psychiatrists and nurses about their impressions of the change and calculated the number of citations from regulators pre-and post-changeover. In addition, a survey was sent to all 212 state psychiatric hospitals. RESULTS: Response rates were: 100% for DDH psychiatrists, 42% for DDH nurses, and 67% for state hospitals. At DDH, clinicians favorably viewed the changeover with 23 (96%) of the 24 psychiatrists reporting a preference for internists having overall responsibility for medical care. There was also a marked reduction in deficiencies cited by regulatory agencies, with 10 prior to the change and only one after the change. Responses to the State Psychiatric Hospital survey revealed that psychiatrists currently provide or are responsible for at least some portion of the medical care at 690% ofall facilities. LIMITATIONS: DDH staffevaluated a change from a system that had not been in place for 3 years. Quality of care measures were not available. How these data generalize to other state hospitals is unknown. CONCLUSIONS: Having internists responsible for medical care was well received by staff and regulatory agencies. Currently, state psychiatric facilities use different approaches to provide medical care. Further research is needed on how quality of care, and ultimately patient safety, may be impacted by these different service delivery models.

epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001. These guidelines describe the precautions healthcare workers should take in three areas: standard principles for preventing HCAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; preventing infections associated with the use of short-term indwelling urethral catheters; and preventing infections associated with central venous catheters. The evidence for these guidelines was identified by multiple systematic reviews of experimental and non-experimental research and expert opinion as reflected in systematically identified professional, national and international guidelines, which were formally assessed by a validated appraisal process. In 2003, we developed complementary national guidelines for preventing HCAI in primary and community care on behalf of the National Collaborating Centre for Nursing and Supportive Care (National Institute for Healthand Clinical Excellence). A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective in preventing HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. Consequently, the DH commissioned a review of new evidence published following the last systematic reviews. We have now updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the original epic guidelines published in 2001 remain robust, relevant and appropriate but that adjustments need to be made to some guideline recommendations following a synopsis of the evidence underpinning the guidelines. These updated national guidelines (epic2) provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. Because this is not always the best possible evidence, we have included a suggested agenda for further research in each section of the guidelines. National evidence-based guidelines are broad principles of best practice which need to be integrated into local practice guidelines. To monitor implementation, we have suggested key audit criteria for each section of recommendations. Clinically effective infection prevention and control practice is an essential feature of protecting patients. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of healthcare in NHS hospitals in England can be minimised.