SPiNCAR: A systematic model to evaluate and guide actions for tackling AMR.

BACKGROUND: Italy records very alarming levels antimicrobial resistance (AMR), so a National Action Plan on Antimicrobial resistance (PNCAR) was developed, adopting the AMR European Union's recommendations based on the results of the ECDC site visit of January 2017. For achieving PNCAR objectives, it is necessary to support and harmonize the implementation of recommendations in all the different healthcare levels (regional authorities and local trusts), so the SPiNCAR project was launched to create a tool for reaching this goal. METHODS: We developed a framework based on a scientific literature and national and international guidelines. Firstly, we identified the major intervention areas for tackling AMR, then, for each area, we built a set of standards, both for regional authorities than for local trusts. Every standard is composed by a set of essential and additional criteria, which refer to a minimum or supplemental performance level respectively. The contents were firstly discussed by the project's team during face-to-face kick-off meetings, then confirmed with Delphi methodology and finally validated through a pilot study. RESULTS: The final framework consists of seven different areas that reflect the PNCAR structure: Governance, Surveillance and Monitoring, Appropriate Use of antimicrobials, Healthcare-associated Infections (HAIs) control and prevention, Education and Training, Alliance among Stakeholders, Implementation. The total number of standards for the regional framework was 34 with 264 criteria and for the local version 36 criteria with 279 standards. CONCLUSION: The ongoing use of this tool, developed on international evidences and recommendations that were tailored on the Italian specific context, allows monitoring the improvement achieved over time and plan the next steps.

Professional attitudes toward incident reporting: can we measure and compare improvements in patient safety culture?

OBJECTIVE: To establish categories of professionals' attitudes toward incident reporting by analyzing the trends in incident reporting while accounting for general risk indicators. DESIGN: The incident reporting system was evaluated over 6 years. Reporting rates, stratified by year and profession, were estimated using the non-mandatory reported events/full-time equivalent (NM-IR/FTE) rate. Other indicators were collected using the hospital's official database. Staff attitudes toward self-reporting were analyzed. Univariate and multivariable analyses were performed. SETTING: A 1000-bed Italian academic hospital. PARTICIPANTS: Staff of the hospital (over 3200 professionals). INTERVENTIONS: None. MAIN OUTCOME MEASURES: NM-IT/FTE rates, self-reported rates, patient complaints/praises, work accidents among professionals and 30-day readmissions. RESULTS: The overall reporting rate was 0.44 (95% confidence interval [CI]: 0.42-0.46) among doctors and 0.40 (95% CI: 0.39-0.41) among nurses. Between 2010 and 2015, only the doctors' reporting rate increased significantly (P = 0.04), from 0.29 (95% CI: 0.25-0.34) to 0.67 (95% CI: 0.60-0.73). Patient complaints decreased from 384 to 224 (P < 0.001) and work accidents decreased from 296 to 235 (P = 0.01), while other indicators remained constant. Multivariable logistic regression showed that self-reporting was more likely among nurses than doctors (odds ratio: 1.51; 95% CI: 1.31-1.73) and for severe events than near misses (odds ratio: 1.78; 95% CI: 1.11-2.87). CONCLUSIONS: Because the doctors' reporting rates increased during the study period, doctors may be more likely to report adverse events than nurses, although nurses reported more events. Incident reporting trends and other routinely collected risk indicators may be useful to improve our understanding and measurement of patient safety issues.

Polytherapy and the risk of potentially inappropriate prescriptions (PIPs) among elderly and very elderly patients in three different settings (hospital, community, long-term care facilities) of the Friuli Venezia Giulia region, Italy: are the very elderly at higher risk of PIPs?

PURPOSE: The aim of this point-prevalence study was to assess the occurrence of polypharmacy and hyperpolypharmacy and the risk of potentially inappropriate prescriptions (PIPs) among elderly and very elderly patients in different health-care settings of the Friuli-Venezia Giulia region in the North-East of Italy. METHODS: Prescription pattern of elderly (65-79 years) and very elderly (>79 years) patients in three different health-care settings [hospitals, general practitioners, and long-term care facilities (LTCFs)] was assessed in March 2014, and PIPs were assessed according to the Beers criteria. Other situations at potentially high risk were checked. RESULTS: A total of 1582 patients (hospital, n = 528; outpatients, n = 527; nursing homes, n = 527) were included. Very elderly were more represented in hospitals (60.4%) and LTCFs (77.1%) than among general practitioners (37.6%). Polypharmacy and hyperpolypharmacy rates ranged 57.7-73.7% and 9.7-15.6%, respectively. The most frequently prescribed drugs were the proton pump inhibitors, whereas the most common PIPs resulted the benzodiazepines. Multinomial regression analysis showed that female sex, age > 79 years, hyperpolypharmacy, and chronic kidney disease were associated with the risk of having ≥2 PIPs. Two situations at high risk of PIPs not contemplated by the Beers criteria were recurrent in the study population and concerned the statins and metformin. CONCLUSIONS: Polypharmacy and hyperpolypharmacy among elderly and very elderly are strictly associated with the risk of multiple PIPs. The findings offer the opportunity to remark that improvement of the knowledge of safe drug use is generally needed in aging societies and may become of utmost relevance among health-care workers operating in LTCFs. Copyright © 2016 John Wiley & Sons, Ltd.

Monitoring Polypharmacy in Healthcare Systems Through a Multi-Setting Survey: Should We Put More Attention on Long Term Care Facilities?

BACKGROUND: Polypharmacy is a main issue of patient safety in all healthcare settings (i.e. increase adverse drug reactions and incidence of drug-drug interactions, etc.). The main object of the study was to evaluate the prevalence of polypharmacy and the appropriateness of drugs prescriptions in the regional health system (RHS) of Friuli Venezia-Giulia Region, Italy. DESIGN AND METHODS: We carried out a point prevalence study in May 2014; 1582 patients ≥65 years were included from: 14 acute hospitals, 46 Long Term Care Facilities (LTCFs) and 42 general practitioners' (GPs) clinics. Data analysis included the evaluation of potentially inappropriate prescriptions (PIPs) taking Beers criteria as a reference. RESULTS: Patients in therapy with 10 drugs or more were 13.5%: 15.2% in hospitals, 9.7% in GPs' clinics and 15.6% in LTCFs. According to Beers criteria we identified 1152 PIPs that involved globally almost half of patients (46.0%): 41.9% in hospitals, 59.6% in LTCFs and 37.0% in GP's clinics. The 53.9% of patients received at least one mainly kidney excreted drug; for these patients the evaluation of serum creatinine was overall present in the 87.7% (747/852): 96.4% in hospital ones, 87.5% in GPs' clinics and 77.8% in LTCFs. LTCFs residents were significantly (P<0.05) more exposed to PIPs and less monitored for the renal function. CONCLUSIONS: A reliable estimation of the phenomenon in all the main healthcare settings is a necessary prerequisite to set tailored policies for facing polypharmacy within a RHS; the results showed the necessity to put a special attention on LTCFs.

An ecological study on the association between characteristics of hospital units and the risk of occupational injuries and adverse events on the example of an Italian teaching hospital.

OBJECTIVES: We explored the association of workplace characteristics with occupational injuries and adverse events in an Italian teaching hospital. MATERIAL AND METHODS: This ecological study was conducted using data routinely collected in the University Hospital of Udine, Northeastern Italy. Poisson regression models were used to investigate, at the hospital unit level, the association between 5 outcomes, including: occupational injuries, patient falls, medication errors, other adverse events and near-misses, and various characteristics of the units. RESULTS: The proportion of female workers in a unit, the average number of sick-leave days and of overtime hours, the number of medical examinations requested by employees, and being a surgical unit were significantly associated with some of the outcomes. CONCLUSIONS: Despite ecological nature of the study, which does not allow for inferences to be drawn at the individual level, the results of our study provide useful clues to support strategies and interventions directed towards healthier work environments and better patient care in hospitals.

Imported rickettsioses in Italy.

BACKGROUND: In Italy few cases of rickettsioses have been reported in travellers and autochthonous cases are attributed predominantly to Rickettsia conorii, the agent of Mediterranean spotted fever. METHOD: The purpose of this study was to investigate some epidemiological and clinical features of tick-borne spotted fever group rickettsiosis acquired abroad or in Italy. Serum specimens collected prospectively from patients with suspected rickettsioses were tested by immunofluorescence assay. A definitive diagnosis was made on the basis of positive serological test results at the WHO collaborative centre for rickettsial diseases, Marseille, France. We compared the clinical features of patients with confirmed rickettsioses and those showing typical clinical symptoms/signs without definitive diagnose. RESULTS: Eight of 26 patients suspected cases had confirmed rickettsioses. All patients were travellers returning from southern Africa (75% Rickettsia africae). Inoculation eschars were significantly more common in patients with confirmed rickettsioses (p = 0.004). CONCLUSIONS: Our study demonstrates that R. africae is the most frequent rickettsia observed in Italian travellers. Prior to receiving the laboratory results, physicians should start empirical treatment on the basis of epidemiologic data (e.g., travel history to Africa), and clinical findings compatible with rickettsioses (e.g., eschars).