PLUS-IS-LESS project: Procalcitonin and Lung UltraSonography-based antibiotherapy in patients with Lower rESpiratory tract infection in Swiss Emergency Departments: study protocol for a pragmatic stepped-wedge cluster-randomized trial.

BACKGROUND: Lower respiratory tract infections (LRTIs) are among the most frequent infections and a significant contributor to inappropriate antibiotic prescription. Currently, no single diagnostic tool can reliably identify bacterial pneumonia. We thus evaluate a multimodal approach based on a clinical score, lung ultrasound (LUS), and the inflammatory biomarker, procalcitonin (PCT) to guide prescription of antibiotics. LUS outperforms chest X-ray in the identification of pneumonia, while PCT is known to be elevated in bacterial and/or severe infections. We propose a trial to test their synergistic potential in reducing antibiotic prescription while preserving patient safety in emergency departments (ED). METHODS: The PLUS-IS-LESS study is a pragmatic, stepped-wedge cluster-randomized, clinical trial conducted in 10 Swiss EDs. It assesses the PLUS algorithm, which combines a clinical prediction score, LUS, PCT, and a clinical severity score to guide antibiotics among adults with LRTIs, compared with usual care. The co-primary endpoints are the proportion of patients prescribed antibiotics and the proportion of patients with clinical failure by day 28. Secondary endpoints include measurement of change in quality of life, length of hospital stay, antibiotic-related side effects, barriers and facilitators to the implementation of the algorithm, cost-effectiveness of the intervention, and identification of patterns of pneumonia in LUS using machine learning. DISCUSSION: The PLUS algorithm aims to optimize prescription of antibiotics through improved diagnostic performance and maximization of physician adherence, while ensuring safety. It is based on previously validated tests and does therefore not expose participants to unforeseeable risks. Cluster randomization prevents cross-contamination between study groups, as physicians are not exposed to the intervention during or before the control period. The stepped-wedge implementation of the intervention allows effect calculation from both between- and within-cluster comparisons, which enhances statistical power and allows smaller sample size than a parallel cluster design. Moreover, it enables the training of all centers for the intervention, simplifying implementation if the results prove successful. The PLUS algorithm has the potential to improve the identification of LRTIs that would benefit from antibiotics. When scaled, the expected reduction in the proportion of antibiotics prescribed has the potential to not only decrease side effects and costs but also mitigate antibiotic resistance. TRIAL REGISTRATION: This study was registered on July 19, 2022, on the ClinicalTrials.gov registry using reference number: NCT05463406. TRIAL STATUS: Recruitment started on December 5, 2022, and will be completed on November 3, 2024. Current protocol version is version 3.0, dated April 3, 2023.

In-between duty and hope for recognition, the experience of physiotherapists working in a university hospital during the COVID-19 first wave in Switzerland: a qualitative study based on focus groups.

BACKGROUND: Learning more about the physiotherapists' experience, perceived role and perception of events during the COVID-19 crisis, as well as their recovery and projection into the post-crisis future, may be useful to inform stakeholders about the impact of the crisis. The objective of this study was to investigate the experience of physiotherapists working in a university hospital in Switzerland during the 1st wave of the COVID-19 crisis, more specifically their subjective experience, professional involvement, perception of management and perceived implications for the future. METHODS: This interpretative qualitative study investigated the subjective experience of a purposeful sample of 12 physiotherapists using two 2 h semi-directive focus group interviews conducted by a physiotherapist in June 2020. Data were recorded, transcribed, and analysed using a thematic analysis approach. The report was approved by participants and the study was audited by a health anthropologist. RESULTS: The most impressive points were the unprecedented nature of the crisis, the health threat, the hospital's capacity to reorganise on a large scale and the solidarity between colleagues. Participants expressed a high level of commitment to their role despite the potentially serious repercussions at an individual level. Pride and stress coexisted for those directly involved in the crisis, while those working in a reduced activity department felt anxious and idle. The need for immediacy in decision-making and action led to a flattening of hierarchies and an increase of uncertainties. Communication management was seen as the main area for improvement. Physiotherapists hoped that their involvement would improve recognition of the profession but feared that working conditions would deteriorate after the crisis. CONCLUSIONS: The physiotherapists expressed high dedication to their profession and pride to be part of the "war effort" during the crisis. The stress level was partly tempered by the solidarity amongst health professionals and distraction by engaging in action. Despite the mental load, this situation was also seen as an opportunity to grow at a personal and professional level. The healthcare system capacity having not been exceeded in Switzerland, less distress related to death and powerlessness were expressed than in other studies investigating healthcare professionals' experience of the COVID-19 crisis.

Patients' expectations of physiotherapists before and after an intensive chronic low back pain rehabilitation programme: a qualitative study based on semi-structured interviews and observations.

PURPOSE: To investigate the expectations regarding physiotherapists of patients attending an interdisciplinary CLBP rehabilitation programme and the response to these expectations. MATERIALS AND METHODS: A thematic analysis was conducted, based on interviews of working-age patients with CLBP and without significant comorbidities. RESULTS: Twenty patients participated (9 male, 11 female, aged 21-58 years; symptoms duration 4.3 ± 3.0 years; pain VAS 53 ± 21 mm). Patients expected to learn pain and activity management. Expected outcomes were a reduction of pain, increased well-being and a return to normality. A collaborative approach involving therapeutic and relational adaptation was expected. Despite divergences concerning emotional aspects, patients expected a large range of applied psychosocial skills.The programme met the expectations of most patients, especially when its goals matched those reported by the individuals. For most participants, the pain relief was below expectations. Active therapies were valued. After the programme, patients felt more ready to take responsibility for their back. CONCLUSION: The expectation of developing self-management skills was prevalent. Expected treatments were mostly compatible with recommendations. Expectations to resume activities and decrease pain were in line with the rehabilitation goals, although the expected reduction in pain was overestimated. Relational expectations converged towards patient-centred care.

Patient­therapist agreement on rehabilitation goals is central to meeting the expectations of patients following a chronic low back pain (CLBP) rehabilitation programme.Physiotherapists should be aware of the wide range of expectations that patients with CLBP have of them in terms of skills development, relationship and outcome.The treatments expected by patients with CLBP were mostly compatible with scientific treatment recommendations.Since expectations are rarely expressed spontaneously during treatment sessions, physiotherapists should regularly enquire about them and their evolution in the course of rehabilitation.Following the programme, the patients' expectations had shifted from focusing on the physiotherapist to taking responsibility for self-management of the CLBP, although they had some doubt about their ability to achieve this.

[Deprescribing in nursing homes: comparative views of residents, their relatives, and healthcare professionals]. / Déprescrire en EMS: regards croisés entre les résidents, leurs proches et les professionnels de la santé.

Deprescribing, in order to reduce both polypharmacy and the use of potentially inappropriate medications, remains a challenge, especially in nursing homes. Healthcare professionals perceive residents of these homes as wary of change and reluctant to take part in such endeavours. The results of two studies, one qualitative and the other quantitative, show that, on the contrary, nursing home residents and their relatives would be ready to consider a treatment reduction, provided that time is invested to explain the expected benefits of such changes.

Déprescrire pour réduire l'usage de médicaments inappropriés et, plus généralement, diminuer la polymédication reste un défi, en particulier chez les résidents d'établissements médico-sociaux. Les professionnels de la santé actifs en institution perçoivent cette population comme réticente au changement et peu encline à s'engager dans une telle démarche. Pourtant, les résultats de trois études, les deux premières qualitatives, la dernière quantitative, indiquent que ces résidents, ainsi que leurs proches, seraient prêts à tester une réduction de leur traitement, pour autant que l'on prenne le temps de discuter avec eux des bénéfices potentiels.

Trajectoires de personnes souffrant de lombalgie chronique : ruptures et reconstructions après un programme de rééducation.

Purpose of research: The objective of this article is to investigate, from the perspective of patients, the disruptions of the biographical trajectories induced by chronic low back pain and the impact of a multidisciplinary rehabilitation program on their reconstruction. METHODS: Based on an interdisciplinary qualitative research, we investigated the experience of 20 participants with chronic low back pain following a three-week rehabilitation program at the hospital. Semi-directive interviews were conducted before and after inclusion in the program. RESULTS: Although affecting each person in a singular way, chronic low back pain induces biographical linearity disruptions related to the apparition of pain, and the disruption of daily and professional activities. For the majority of participants, the rehabilitation program provided a repairative space to restore continuity between past, present and future life. Whether or not there is a significant improvement in pain, most participants report benefits that give them the feeling of getting back to normality. Nevertheless, they identify those more for the domestic, family, and social spheres than at the professional level, effects remaining moderate to mitigated in that area. CONCLUSIONS: The rehabilitation program influences the dynamics of biographical trajectories and promotes a return to what is perceived as normality. By providing individuals with theoretical and practical tools and increasing their functional capacities, it promotes autonomous pain and problem management. Immediate effects are seen as restorative for domestic, family and social activities, but remain limited on the professional level.

Satisfaction and experiences of patients taking fingolimod and involved in a pharmacy-based patient support program in Switzerland - a qualitative study.

BACKGROUND: Fingolimod is an oral multiple sclerosis drug that is considered a specialty drug due to its high cost and safety issues. The Fingolimod Patient Support Program (F-PSP) is a specialty pharmacy service developed to ensure the responsible use of fingolimod by promoting patient safety and medication adherence. This study aims to explore the satisfaction, experiences and perceptions regarding the F-PSP among patients currently involved in this program or recently withdrawn. METHODS: A qualitative study was conducted via individual, face-to-face semistructured interviews with patients involved in the F-PSP. The interviews were audio-recorded, transcribed verbatim, coded and analyzed via thematic content analysis. RESULTS: The main themes identified from the interviews (n = 17) were overall perception of the F-PSP, perception of the pharmacist-led consultations, perception of the tools (electronic monitor and drug intake graph), reasons to participate or potentially withdraw, and suggestions for improvements. Participants perceived the F-PSP as a reassuring support that complemented their medical care, providing a more human, personalized and person-centered approach than usual pharmacy care. Pharmacist-led consultations were valued for the medication-related and holistic support they provided. The importance of the pharmacist's attitude was emphasized. The electronic monitor was valued for promoting daily medication adherence and allowing the involvement of relatives, which reassured participants and their relatives. The participants appreciated the drug intake graph because it provided an objective overview of medication adherence, thereby reassuring, rewarding, and motivating them. The main reason to join the program was to be supported, especially with respect to medication adherence. CONCLUSIONS: Participants were satisfied with the F-PSP, each for different reasons. Their feedback enabled the identification of measures for the optimization of the F-PSP and should facilitate its dissemination and transfer to other drugs/diseases/populations. Essential elements of generic pharmacist-led patient support programs considered valuable from the patients' perspective were identified.

Physicians', Nurses' and Pharmacists' Perceptions of Determinants to Deprescribing in Nursing Homes Considering Three Levels of Action: A Qualitative Study.

Background: Polypharmacy and the use of potentially inappropriate medications are frequent safety issues among nursing home (NH) residents. Deprescribing can significantly reduce the number of drugs used, medication costs, and mortality. This qualitative study sought to understand and compare the perceptions and practices of nurses, pharmacists, and physicians regarding deprescribing in Swiss NHs, referring to an implementation approach on three levels of action: the individual, the institution, and the healthcare system. Methods: Two focus groups were held with 21 participants: one focus group with 11 pharmacists, another with 10 nurses and six semi-structured interviews with physicians were conducted and focused on their individual experience and practices. They were audiotaped and fully transcribed, and a content analysis was performed using to MAXQDA (Ver 12) software. Results: (1) At an individual level, physicians were concerned by consequences of deprescribing in terms of safety. Nurses were closest to residents and stressed the importance of finding the right time, creating a bond of trust before deprescribing and considering the purpose of the stay in the NH. Pharmacists relied on structured guides for deprescribing, which led their reflection and practice. All professionals saw the complexity of the clinical situations, as well as residents' and relatives' fears of interruption of care. (2) At an institutional level, the professionals stressed the lack of time to discuss patients' health and treatment, while pre-existing interprofessional collaboration, specifically, quality circles, seemed useful tools to create common knowledge. In order to reduce prescriptions, better coordination between physicians, nurses, pharmacists and specialists seemed crucial. (3) At the health system level, funding still needs to be provided to consolidate the process, go beyond organisational constraints and ensure deprescribing serves the patient's wellbeing above all. Conclusions: At the individual level of implementation, the different healthcare professionals expressed specific concerns about deprescribing, depending on their defined role in NHs. Their perspective about the different levers to promote deprescribing at institutional and healthcare system levels converge towards interprofessional collaboration supported by the healthcare system. Specific funding and incentives are therefore needed to support a sustainable interprofessional team.

Rising to the medication's requirements: The experience of elderly cancer patients receiving palliative chemotherapy in the elective oncogeriatrics field.

A new subfield of oncology has emerged in the last twenty years to raise awareness and address the specific needs of elderly cancer patients, a population that was long neglected in oncology. We sought to understand the individual experiences, as well as moral and social implications of considering elderly cancer patients as "treatable". Following an anthropological critical interpretative approach focusing on practical and symbolic effects of chemotherapy in a rapidly evolving medical field, we conducted 20 semi-structured interviews and observations of medicine storage places at home among elderly cancer patients aged 70 and over in a clearly incurable situation receiving palliative chemotherapy. We used photographs representing paths as triggers in interviews, and compared the patients' views with those of 12 health professionals in oncology during a brief open-ended interview. Elderly cancer patients consider themselves to be survivors and fighters. Their long trajectory is a result of their successful struggle and tolerance of the treatments allowing them to carry on. They continually observe their physical ability and test their resistance, they resist complaining and are grateful to have cancer at a late stage of life. By highlighting their active life rather than the treatment inconveniences, they show they are "young elderly" persons, capable of keeping active physically. They are treated precisely because they demonstrated that they had the physical and moral capacity to take the hit of the chemotherapy to their bodies and had the will to fight. The development of oncogeriatrics has enabled the treatment of the fittest cancer patients over 70, but the ethical debate to treat some elderly patients and not others, and decisions of therapeutic abstention facing frail elderly cancer patients remains an issue rarely discussed. This aspect should not be eluded by the important progress achieved in medicine facing cancer.

[Oncology trajectories of elderly patients in a palliative situation : « The long and winding road ¼]. / Trajectoires oncologiques de personnes âgées en situation palliative: « The long and winding road ¼.

This paper focuses on trajectories of elderly patients with metastatic cancer who experience several lines of systemic palliative cancer treatments. Based on photographs representing paths, the representations between patients and professional caregivers vary. Where the latter see wearisome treatments and spaces of negotiation, the patients wish to be seen as fighters, a figure that ought to be adopted to face cancer and its treatments, day after day, to meet medical and social expectations.

Cet article s'intéresse aux trajectoires des personnes âgées atteintes de cancer métastatique qui font l'expérience de plusieurs lignes de traitements oncologiques systémiques palliatifs. Sur la base d'un choix de photos évoquant des parcours, les représentations entre les patients et les soignants diffèrent. Là où ces derniers voient la pénibilité des traitements et des espaces de négociation, les patients veulent être appréhendés comme des battants, figure qu'il convient d'adopter pour faire face au cancer et aux traitements, jour après jour, et correspondre aux attentes médicales et sociales.

[Chronic low back pain: from the uncertain medical diagnosis to the profane etiologies]. / Lombalgie chronique : du diagnostic médical incertain aux étiologies profanes.

This qualitative research article is based on interviews with 20 participants to a low back pain rehabilitation program in a Swiss hospital. It shows that, in the absence of the obvious cause that can explain pain, patients construct their own interpretations and explanations in order to give meaning to their experience. Their explanatory models mainly include the lifestyle and the physical aspects related to the body function, what leaves little room for the psychosocial component. Their interpretation is consequently discordant with the current medical approach, which considers that chronic low back pain results from bio-psycho-social factors. This discrepancy implies negotiation between patients and professionals about the objectives to achieve in order to treat pain.

Cet article, issu d'une recherche qualitative menée dans un hôpital suisse, est basé sur des entretiens avec 20 participants à un programme de rééducation de la lombalgie. Il montre qu'en l'absence de causes objectivables permettant d'expliquer la douleur, les patients élaborent leurs propres interprétations et explications pour donner sens à leur vécu. Leurs modèles explicatifs incluent principalement le mode de vie et les aspects physiques liés au fonctionnement du corps et laissent peu de place à la composante psychologique. Leur interprétation est, par conséquent, en décalage avec la vision médicale actuelle qui considère que les douleurs dans la lombalgie chronique sont d'origine bio-psychosociale. Ce décalage implique une concertation entre patients et professionnels sur les objectifs à poursuivre pour traiter la douleur.

Attitudes Regarding Palliative Sedation and Death Hastening Among Swiss Physicians: A Contextually Sensitive Approach.

In Switzerland, where assisted suicide but not euthanasia is permitted, the authors sought to understand how physicians integrate palliative sedation in their practice and how they reflect on existential suffering and death hastening. They interviewed 31 physicians from different care settings. Five major attitudes emerged. Among specialized palliative care physicians, convinced, cautious and doubtful attitudes were evident. Within unspecialized settings, palliative sedation was more likely to be considered as death hastening: clinicians either avoid it with an inexperienced attitude or practice it with an ambiguous attitude, raising the issue of unskilled and abusive uses of sedatives at the end of life.

The use of palliative sedation: A comparison of attitudes of French-speaking physicians from Quebec and Switzerland.

OBJECTIVE: Previous literature has suggested that laws and regulations may impact the use of palliative sedation. Our present study compares the attitudes of French-speaking physicians practicing in the Quebec and Swiss environments, where different laws are in place regarding physician-assisted suicide. METHOD: Data were drawn from two prior studies, one by Blondeau and colleagues and another by Beauverd and coworkers, employing the same two-by-two experimental design with length of prognosis and type of suffering as independent variables. Both the effect of these variables and the effect of their interaction on Swiss and Quebec physicians' attitudes toward sedation were compared. The written comments of respondents were submitted to a qualitative content analysis and summarized in a comparative perspective. RESULTS: The analysis of variance showed that only the type of suffering had an effect on physicians' attitudes toward sedation. The results of the Wilcoxon test indicated that the attitudes of physicians from Quebec and Switzerland tended to be different for two vignettes: long-term prognosis with existential suffering (p = 0.0577) and short-term prognosis with physical suffering (p = 0.0914). In both cases, the Swiss physicians were less prone to palliative sedation. SIGNIFICANCE OF RESULTS: The attitudes of physicians from Quebec and Switzerland toward palliative sedation, particularly regarding prognosis and type of suffering, seem similar. However, the results suggest that physicians from Quebec could be slightly more open to palliative sedation, even though most were not in favor of this practice as an answer to end-of-life existential suffering.

Description of a Tertiary Swiss University Hospital palliative population based on the International Classification of Disease (ICD): a retrospective pilot study.

BACKGROUND: The factors for assessing the utilization rate of a palliative care service are various and complex. Several authors have described different methods to address this problem. McNamara and colleagues have proposed criteria to determine "minimal," "mid-range," and "maximal" palliative population estimates. In order to evaluate the utilization of our intrahospital palliative care consult team (PCT), it appeared necessary to better describe and define the population who dies in our institution, a Swiss university hospital. The goal of this pilot study was to determine what percentage of patients who died in our hospital over a 4-month period in 2007 was seen by the palliative care consult team (PCT), using "minimal" and "maximal" population estimates. METHODS: The hospital database was searched for all adult patients who died during that period and the "maximal" and "minimal" populations determined. The PCT's database was searched to identify those patients who had been seen by the PCT. The charts of a random sample of patients who did not initially meet the "minimal" criteria were hand searched. RESULTS: A total of 294 adult deaths were reported: 263 (89%) met the "maximal" criteria and 83 (28%) met the "minimal" criteria initially. The random search of 56 charts of the 180 patients who did not meet the "minimal" criteria revealed that 21 (38%) should have been included in the "minimal" population. The PCT saw 67/263 (25.5%) of the "maximal" palliative patient population and 56/151 (37.1%) of the "minimal" palliative population. CONCLUSION: This study highlights the usefulness of the method proposed by McNamara and colleagues to determine palliative populations. However, it also illustrates an important limitation of the "minimal" estimate and reliance on the accuracy of the cause of death as noted on the death certificate. A strategy to address this limitation is suggested. The "maximal" estimate suggests that the PCT is being underutilized.