Surgical Site Infection in Endometriosis Surgery Is a Rare Complication: Results of a Single Center's Prospective Surveillance of Eight Hundred Ninety-Six Procedures.

Background: There are no studies reporting the rate of surgical site infection (SSI) after surgery for endometriosis, although this information is valuable when discussing the most appropriate treatment strategy with the patient. Methods: We conducted a prospective cohort study in a university hospital and regional reference center for endometriosis. We sought to measure the rate of SSI after endometriosis surgery using prospective SSI post-discharge surveillance data and the hospital information system via an ad hoc algorithm using both diagnosis and procedure code classifications. Results: Among 896 consecutive endometriosis surgical procedures, we identified 365 procedures with involvement of the gastrointestinal tract, defined as the deep invasive procedure (DIP) group, 107 procedures with involvement of an ovary, and 424 other procedures. Twelve SSI (all organ/space infections) were observed, all in the DIP group, corresponding to an overall SSI incidence of 1.3% 95% confidence interval (CI) 0.7-2.3, and an SSI incidence in the DIP group of 2.8%, 95% CI 1.5-4.9. The median delay between the procedure and the SSI was 6.5 days (range, 3-23). At least one micro-organism was found in 10 patients (four Escherichia coli, four Enterobacter cloacae, three Enteroccus faecalis, two Bacteroides fragilis, one Pseudomonas aeruginosa, one Candida albicans). Conclusion: A low overall rate of SSI after surgery for endometriosis was observed. Nevertheless, procedures with involvement of the intestinal tract were at risk of SSI.

The impact of a patient's social status on the cost of vaginal deliveries: an observational study in a French university hospital.

INTRODUCTION: We aimed to assess the association between a patient's social status and the cost of stay for a single uncomplicated vaginal delivery. Currently, few data have been reported. MATERIAL AND METHODS: We conducted an observational study with data retrieved from the medical and administrative databases of a university hospital in North-West France. We included all patients admitted in 2014 and classified in either Diagnosis-Related Group (DRG) « Single uncomplicated vaginal deliveries in a primiparous patient ¼ or DRG « Single uncomplicated vaginal deliveries in a multiparous patient ¼. Criteria defining poor social status were: a specific healthcare benefit in relation to low income or for foreign undocumented patients, and/or a consultation with a social worker during the hospital stay except if no social problem was diagnosed. We compared the cost of stay between patients with poor social status and patients with good social status using a multivariate median regression stratified on parity, and adjusted for age, gestational age and neonatal hospitalization. RESULTS: Among 686 primiparous patients, 21% had poor social status, which was associated with an increase in the median cost of stay (+€475; 95% CI [+334 to +616]), mostly explained by a 1-day increase in the median length of stay.Among 899 multiparous patients, 29% had poor social status, which was not associated with the cost of stay. DISCUSSION: Social status had an impact on the cost of vaginal deliveries in primiparous patients. Our findings suggest a need to redefine the DRG classification according to patients' social status.

Surveillance of unplanned return to the operating theatre in neurosurgery combined with a mortality--morbidity conference: results of a pilot survey.

BACKGROUND: Unplanned return to the operating theatre (UROT) is a useful trigger tool that could be used to identify surgical adverse events (SAEs). The present study describes the feasibility of SAE surveillance in neurosurgical patients, based on UROT identification, completed with SAE analysis at a morbidity-mortality conference (MMC) meeting. METHOD: For consecutive patients who underwent a neurosurgical procedure between 1 November 2008 and 30 April 2009, return to the operating theatre (ROT) was identified based on the hospital information system associated to prospective payment (HISPP). ROT was classified as planned or unplanned and UROT was further classified as related to the natural history of the disease or related to an adverse event (AE-UROT). MMC meetings were organised to discuss results of UROT surveillance and to analyse AE-UROT. RESULTS: 1006 neurosurgical procedures were included in the surveillance. HISSP identified 152 ROTs, with 73 UROTs related to an SAE (7.3% (5.7% to 9.0%)): infectious SAE (n=24, 2.4% (1.5% to 3.5%)), haemorrhagic SAE (n=23, 2.3% (1.5% to 3.4%)), other cause SAE (n=26, 2.8% (1.9% to 4.0%)), and infectious and other cause SAE (n=2, 0.2% (0.0% to 0.7%)). Identification of AE-UROT through HISSP required a 4 h/month time frame. Eight UROTs related to SAE cases were discussed during MMC meetings, leading to the identification of non-conforming care processes and practical improvement actions. CONCLUSION: UROT related to SAE surveillance in neurosurgical patients was considered feasible. The association of surveillance and MMCs allowed staff to concentrate on the analysis of most frequent or most severe AEs and was a practical and useful tool to stimulate improvement. The impact on healthcare quality of SAE surveillance associated with MMC warrants further research.

Is continuous subglottic suctioning cost-effective for the prevention of ventilator-associated pneumonia?

OBJECTIVE: To establish whether continuous subglottic suctioning (CSS) could be cost-effective. DESIGN: Cost-benefit analysis, based on a hypothetical replacement of conventional ventilation (CV) with CSS. SETTING: A surgical intensive care unit (SICU) of a tertiary care university hospital in France. PATIENTS: All consecutive patients receiving ventilation in the SICU in 2006. METHODS: Efficacy data for CSS were obtained from the literature and applied to the SICU of our hospital. Costs for CV and CSS were provided by the hospital pharmacy; costs for ventilator-associated pneumonia (VAP) were obtained from the literature. The cost per averted VAP episode was calculated, and a sensitivity analysis was performed on VAP incidence and on the number of tubes required for each patient. RESULTS: At our SICU in 2006, 416 patients received mechanical ventilation for 3,487 ventilation-days, and 32 VAP episodes were observed (7.9 episodes per 100 ventilated patients; incidence density, 9.2 episodes per 10,000 ventilation-days). Based on the hypothesis of a 29% reduction in the risk of VAP with CSS than CV, 9 VAP episodes could have been averted. The additional cost of CSS for 2006 was estimated to be €10,585.34. The cost per averted VAP episode was €1,176.15. Assuming a VAP cost of €4,387, a total of 3 averted VAP episodes would neutralize the additional cost. For a low VAP incidence of 6.6%, the cost per averted VAP would be €1,323. If each patient required 2 tubes during ventilation, the cost would be €1,383.69 per averted VAP episode. CONCLUSION: Replacement of CV with CSS was cost-effective even when assuming the most pessimistic scenario of VAP incidence and costs.

Does comparison of performance lead to better care? A pilot observational study in patients admitted for hip fracture in three French public hospitals.

OBJECTIVE: To assess whether comparison of quality of hip fracture care among three teams located in different hospitals is associated with improvement in process and outcomes. DESIGN: A baseline assessment was performed using quality indicators selected by professionals. RESULTS: were discussed among the three teams followed by a post-comparison assessment of the same indicators. SETTING: Three hospitals in North Western France. PARTICIPANTS: Professionals caring for patients operated on for a low-impact hip fracture. INTERVENTION: Review and discussion of comparative performance results by three teams followed by implementation of quality improvement as deemed necessary by each team. MAIN OUTCOME MEASURES: Fifteen quality indicators of health care during orthopedic and rehabilitation stay, mobility, dependence and place of residence before hip fracture and 3 months after discharge, 3 month post-surgery mortality and readmission rates. RESULTS: Major differences were observed among hospitals throughout the care process during baseline period. Comparison of performance and discussion among the three teams were followed by corrective action in 11 areas. After comparison, a significant improvement was observed in 10 areas, seven of which corresponded to quality improvement areas chosen for improvement action by professionals. A significant decrease in readmission rate (6.7% vs. 15.7%, P < 0.001) was observed but there was no change in mortality, functional outcome or length of stay. CONCLUSIONS: Comparison of performance among voluntary teams, on fields selected by health-care professionals, was associated with improvement in the care process and with improvement of some related outcomes.

Efficiency of hepatitis C virus screening strategies in general practice.

UNLABELLED: Hepatitis C viral infection (HCV) is a frequent and severe disease; screening strategies to-date remain insufficient. OBJECTIVE: To assess the efficiency of HCV screening of high-risk groups among patients consulting general practitioners. METHODS: A cost-effectiveness analysis was performed involving general medicine screening practices recorded during a survey of 127 practitioners (10,041 patients) conducted in 1997. A reference strategy, defined as HCV screening for illicit drug users and transfused patients, and five extended strategies, where the screening population was broadened to include other risk groups as well, were considered. Average cost and marginal cost-effectiveness ratios were determined for each extended strategy and compared with those observed for the reference strategy. The sensitivity of HCV screening to funding modalities, HCV seroprevalence and proportion of HCV high-risk groups among patients attending general practitioners was studied. RESULTS: The reference strategy was the most cost-effective method irrespective of the funding modality considered. Fixed practitioner payment was the least efficient funding modality. The average cost of one positive test was sensitive to variations of HCV seroprevalence in the high-risk group as well as the proportion of high-risk patients among the general practitioners' patients. CONCLUSION: Extension of hepatitis C screening to risk groups other than transfused patients and illicit drug users implies a substantial increase in healthcare costs as well as social consensus for such expenditures.

[Choice of a strategy for screening for methicillin-resistant Staphylococcus aureus on admission to rehabilitation units]. / Choix d'une stratégie de dépistage du Staphylococcus aureus résistant à la méticilline à l'admission en service de soins de suite et de réadaptation.

OBJECTIVE: To identify a strategy of MRSA screening (methicillin-resistant Staphylococcus aureus) on admission to geriatric rehabilitation units, which would lead to acceptable efficacy and cost compared with a reference maximaliste strategy combining all six sampling sites. Method MRSA screening was conducted prospectively for 3 months in all the patients admitted to a geriatric follow-up and rehabilitation unit, using samples from the nostrils, armpits, urine scars cutaneous ulcers and sores. Six strategies were defined combing different sampling sites. Their efficacy and cost were compared with those of a maximaliste strategy combining the 6 sampling sites. RESULTS: Combined screening of all six sites was the most effective but also the most expensive strategy. The least expensive strategy used only samples from ulcers and sores, but its efficacy was of only 45%. The strategy with the lowest loss of efficacy compared to the reference strategy combined the sampling of ulcers and sores and sampling from the nostrils: it was efficient in 91% and its cost was 2.5 fold lower than the cost of the reference strategy. DISCUSSION: A preliminary, short term study established an MRSA screening strategy adapted to the specificities of a geriatric rehabilitation unit and its recruitment. The ability to define the optimal strategy for MRSA screening in a geriatric rehabilitation and follow-up unit may be an important factor in controlling the diffusion of MRSA.