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Le taux de suicide à l'hôpital psychiatrique est élevé. L'amélioration du repérage des patients à risque suicidaire et de la prévention du passage à l'acte durant l'hospitalisation est nécessaire. Dans le cadre d'un groupe de travail d'évaluation des pratiques professionnelles sur le risque suicidaire à l'hôpital Sainte-Anne à Paris, nous avons étudié huit cas de suicide de patients hospitalisés entre 2009 et 2018. Cette étude qualitative a porté sur les retours d'expériences (REX) des équipes multidisciplinaires de soins et la lecture des dossiers médicaux. L'analyse montre que tous les patients de notre étude présentaient des antécédents personnels de tentatives de suicide (notamment avec un moyen violent), dont la moitié d'entre eux durant un séjour hospitalier antérieur. La majorité des décès par suicides sont intervenus lors d'un week-end ou d'un jour férié et à l'intérieur même des unités d'hospitalisation. Le moyen de suicide le plus fréquemment retrouvé était la pendaison. Au regard des résultats de notre série de cas et des données de la littérature, l'histoire suicidaire personnelle est le facteur de risque de passage à l'acte en milieu hospitalier le plus fréquent. Toutefois, la prédictibilité du suicide reste faible en pratique clinique et tous les patients hospitalisés en psychiatrie devraient être considérés à haut risque de suicide durant l'hospitalisation et à la sortie. En amont, la prévention du suicide à l'hôpital repose avant tout sur la sécurisation du milieu hospitalier (inventaire à l'entrée, mobilier anti-suicide, blocage de l'accès aux hauteurs et de l'ouverture des fenêtres, etc.). La formation spécifique et répétée des équipes soignantes au risque suicidaire, la couverture de la permanence des soins, la mise en place de procédures d'évaluation et de surveillance, ainsi que la transmission et la traçabilité systématiques de ce risque sont également des actions organisationnelles de prévention des actes suicidaires à l'hôpital. Au niveau individuel, la qualité du contact avec le patient, le travail avec l'entourage et le traitement actif de la maladie mentale et de ses comorbidités sont essentiels. Après une tentative de suicide ou un suicide survenu à l'hôpital, le partage systématique d'expérience devrait être institué afin d'améliorer les pratiques. La mise en œuvre de mesures de postvention pour le soutien aux autres patients et aux soignants de l'unité, ainsi qu'à l'entourage, devrait compléter le dispositif. Inpatient suicide rates are high at the psychiatric hospital. Improvement in detecting suicidal patients and preventing suicidal acts during hospitalization is essential. As part of a working group on the evaluation of professional practices on suicide risk at Sainte-Anne Hospital in Paris, we retrospectively studied eight cases of inpatient suicides that occurred between 2009 and 2018. We conducted a qualitative analysis of multidisciplinary morbidity and mortality reviews and medical records data. In our case series, all patients had a personal history of suicide attempts (notably using a violent means), and half of them previously attempted suicide during hospitalization. In most cases, suicide occurred during weekends or public holidays and inside care units. Suicide by hanging was the most prevalent method. Regarding our results and the literature, a past personal suicide attempt is the most frequent risk factor for inpatient suicide. However, prediction of suicide remains weak and all psychiatric inpatients should be considered at significant risk of suicide during hospitalization and just after discharge. Inpatient suicide prevention is primarily based on a safer hospital environment (inventory at entry, anti-suicidal furniture, no height access and windows opening, etc.). In addition, specific and repeated suicide training for care teams, continuity of care, enhanced management with assessment and monitoring protocols, good teamwork communication and better traceability of suicide risk in records appear to be organizational requirements for inpatient suicide prevention. At the individual level, quality of contacts with the patient, interactions with relatives and significant others, and active treatment of psychiatric disorders and comorbidities are fundamental. After a suicide or suicide attempt at the hospital, experience sharing should be systematically put into place to improve care practices. The implementation of postvention measures with the aim to support other patients and caregivers in the affected medical unit, as well as the victim's relatives, should complete the actions to lead. [ABSTRACT FROM AUTHOR]

Résumé Introduction Les inhibiteurs de la pompe à protons (IPP) sont largement prescrits pour des indications non reconnues, à forte dose, pour une durée prolongée, malgré des effets indésirables et des interactions médicamenteuses nombreux. En 2009, la HAS a publié des recommandations de bonne prescription mais ces dernières sont peu respectées. Dans ce contexte de surprescription et de surcoût pour la société, nous avons réalisé une évaluation des pratiques professionnelles sur le modèle de la roue de Deming. L’objectif de ce travail était d’optimiser la pertinence des prescriptions des IPP dans deux services de médecine interne et de gériatrie grâce à une évaluation des pratiques professionnelles. Toutes les prescriptions d’IPP étaient analysées qu’elles aient été initiées en externe ou durant l’hospitalisation. Patients et méthodes Le recueil des données était prospectif, sur deux périodes de 2 mois et incluait 163 (première phase) puis 139 patients (deuxième phase). Une grille d’évaluation des prescriptions d’IPP était remplie par les médecins concernant le principe actif, la posologie, la durée et l’indication de la prescription. La pertinence correspondait aux prescriptions d’IPP avec une indication et une durée conformes et aux prescriptions non recommandées arrêtées. À la suite de la première période de recueil des données, une information des internes et médecins sur la pertinence de leurs prescriptions au regard des recommandations actuelles et la distribution de plaquettes d’aide à la prescription étaient faites dans le but d’améliorer les pratiques avant la seconde période d’évaluation (deuxième phase). Résultats Lors de la première phase, seulement 25 % des prescriptions pré-hospitalières et 33 % des prescriptions hospitalières respectaient les recommandations de la HAS. La principale indication des IPP était la prévention d’ulcères gastroduodénaux dans un contexte de prise médicamenteuse estimée à risque. Une amélioration de la pertinence des prescriptions était observée après la sensibilisation des prescripteurs : pertinence de 26 % lors de la première phase à 60 % après rappel auprès des prescripteurs ( p < 0,012). Lors de la seconde phase, la part des prescriptions d’IPP initiées à l’hôpital diminuait de 33 à 17 % et l’arrêt de l’exposition non recommandée avec information des médecins correspondants augmentait de 6 à 33 % ( p < 0,001). Cependant, lors de la deuxième phase, 33 % des prescriptions initiées en hospitalisation étaient toujours non recommandées et 61 % des prescriptions débutées en externe non conformes étaient toujours poursuivis à la sortie, probablement par manque d’information suffisante pour arrêter la prescription d’IPP. Conclusion Notre étude souligne le non-respect fréquent des recommandations dans la prescription des IPP. De manière intéressante, une évaluation des pratiques professionnelles a permis une amélioration de la pertinence des prescriptions avec un arrêt plus fréquent des expositions chroniques non conformes et une baisse des prescriptions hors indications. Notre étude suggère qu’il est primordial de poursuivre la sensibilisation des internes et des médecins hospitaliers et de ville dans leur prescription d’IPP. Une information des patients sur les indications et la durée limitée de la prescription, les effets indésirables potentiellement graves d’une prise prolongée et le risque d’interactions médicamenteuses reste également nécessaire pour faciliter l’arrêt de l’exposition et limiter l’automédication. Introduction Proton pump inhibitors (PPI) are widely prescribed for unrecognized indications, at high a dose and for a long duration, in spite of side effects and numerous drug interactions. In 2009, the HAS (French Health Authority) published recommendations of good prescription but the latter are poorly respected. In this context of over prescription and additional cost for the society, we performed a professional practice evaluation of on the model of the Deming wheel. The objective of this work was to optimize the relevance of the prescriptions of the IPP in two services of internal medicine and geriatrics through an evaluation of the professional practices. All PPI prescriptions introduced in outpatient visits or during hospitalization were analyzed. Patients and methods Data collection was prospective, over two periods of 2 months and included 163 (first phase), then 139 patients (second phase). An assessment grid of PPI prescriptions was completed by physicians regarding the active substance, the dose, the duration and the indication of the prescription. The relevance of the prescription corresponded to PPI with a conformed indication and duration and to the prescriptions no recommended stopped. Following the first period of data collection, information was given to medical students and physicians on the relevance of their prescriptions with regard to the current recommendations and informative flyers were offered with the aim of improving the practices before the second period of evaluation (second phase). Results During the first phase, only 25% of the pre-hospital prescriptions and 33% of the hospital prescriptions respected the HAS recommendations. The main indication of the PPI was the prevention of peptic ulcers in a context of associated drug estimated at risk. An improvement of the global relevance of prescription was observed after awareness of the physicians: 26% relevance during the first phase and 60% in the second one ( P < 0.012). During the second phase, the part of PPI prescriptions introduced at hospital decreased from 33 to 17% and the discontinuation of the not corresponding prescriptions increased from 6 to 33%, with an additional information given to the general practitioner ( P < 0.001). However, during the second phase, 33% of the prescriptions introduced in hospitalization were always not corresponding and 61% of the not corresponding prescriptions begun in outpatient visits were always pursued on discharge, probably due to the lack of sufficient information to stop the prescription. Conclusion Our study underlines the frequent disrespect of the indications in the prescription of PPI. Interestingly, a professional practices evaluation improved the relevance of the prescriptions with a more frequent withdrawal of the not corresponding exposure and a decrease in global not corresponding prescriptions. Our study suggests that it is crucial to regularly inform physicians on the good prescription of PPI. Patient information focused on the indications and the limited duration of PPI prescription, potentially severe side effects of chronic exposure and on the risk of drug interactions also remains necessary in order to facilitate the stop of the exposure and restrict self-medication. [ABSTRACT FROM AUTHOR]

Résumé Introduction La prescription aux adolescents d’antipsychotiques, est responsable d’effets secondaires importants. Elle impose un bilan pré-thérapeutique ainsi qu’une surveillance régulière et oblige à penser l’articulation entre les soignants. Objectif Évaluer par un audit les pratiques professionnelles concernant les prescriptions d’antipsychotiques à l’adolescence durant une hospitalisation (information délivrée, bilan pré-thérapeutique et suivi, articulation avec les médecins en aval). Patients et méthode Ont été considérés tous les patients hospitalisés dans le département de psychiatrie de l’IMM entre le 1/01 et 31/12/2014. La méthode retenue était l’audit de dossiers selon trois axes : la traçabilité de l’information délivrée au patient concernant les traitements antipsychotiques, le bilan pré-thérapeutique (suivi clinique et biologique), les effets secondaires et la transmission de ces informations aux partenaires de soins en aval de l’hospitalisation. Résultats La trace de l’information délivrée au patient et à sa famille est absente dans la majorité des dossiers. Si la traçabilité du bilan et du suivi était bonne, celle de la survenue d’effets indésirables était davantage lacunaire. La transmission des éléments du suivi à mettre en œuvre aux médecins en aval est apparue variable d’une unité à l’autre. Conclusion Les outils de suivi ont été perfectionnés et d’autres ont été créés. Une formation à la prescription d’antipsychotiques a été mise en place. Cette évaluation des pratiques professionnelles a permis la mobilisation des équipes soignantes tant dans leur dynamique interne que sur le sens de leurs pratiques, cela au bénéfice de la sécurité des patients. Introduction The prescription of antipsychotics for teenagers is responsible for important side effects. It imposes a pre-therapeutic assessment and a regular supervision. This suggests that the relations among the different medical staff have to be assessed. Objective To estimate by an audit the professional practices concerning the prescriptions of antipsychotics to the adolescent during a hospitalization (delivered information, pre-therapeutic assessment and follow-up, joint with the medical doctors operating downstream). Patients and method All the patients hospitalized in the department of psychiatry of the IMM between 1/01 and in 31/12/2014 have been considered. The selected method was the audit of files, per three axis: the traceability of the information given to the patient about the antipsychotic treatments, the pre-therapeutic assessment (followed clinical and biological), the side effects and the transmission of this information to the care partners who acted prior to the hospitalization. Results There is no record of information, delivered to the patient and to its family, in the majority of files. If the assessment traceability and the follow-up were evaluated as being good, that of side effects was more incomplete. The transmission of the elements of the follow-up that need to be implementedtransmitted to the downstream medical doctors seemed to vary from one unity to another. Conclusion Follow-up tools were perfected and others created. A training in the prescription of antipsychotics has been organized. This evaluation of the professional practices allowed the mobilization of the medical teams, both in their internal dynamics and for the sense of their practices, all of it for the benefit and the safety of patients. [ABSTRACT FROM AUTHOR]

Résumé La découverte d’un souffle systolique cardiaque est fréquente en unité. Souvent bénin chez l’adulte jeune asymptomatique, le souffle peut révéler une valvulopathie qui pourrait s’aggraver lors des activités physiques ou une cardiopathie exposant à un risque de mort subite. Cette étude a pour but d’évaluer l’efficience diagnostique du médecin d’unité devant la découverte d’un souffle systolique chez un jeune patient asymptomatique. Matériels et méthode Ce travail prospectif d’un an a impliqué les trois centres médicaux des armées de Bretagne et les cardiologues de l’hôpital d’instruction des armées de Brest. La population étudiée regroupait des militaires de moins de 40 ans asymptomatiques sans cardiopathie sous-jacente connue. Le médecin d’unité a recueilli les caractéristiques du souffle et de l’ECG de manière anonyme en proposant un diagnostic : souffle innocent ou organique. Secondairement, le cardiologue a procédé de même puis a réalisé une échocardiographie délivrant le diagnostic final. Résultats Cinquante-huit patients ont été adressés, 5 ne respectant pas les critères d’inclusion. Sur les 53 patients inclus, le médecin d’unité a retrouvé 46 souffles innocents et 7 souffles organiques. Le cardiologue a retrouvé 51 souffles innocents et 2 souffles organiques. L’échocardiographie n’a retenu qu’un souffle organique dépisté par le cardiologue mais considéré comme innocent en unité (lié à une bicuspidie aortique). Discussion La majorité des souffles diagnostiqués innocents en unité (45/46) ont été confirmés. Parmi les 7 souffles considérés organiques, les arguments séméiologiques relevés (intensité supérieure à 3, persistance à l’orthostatisme, irradiation diffuse) procèdent des critères habituellement cités dans la littérature et témoignent de bons réflexes auscultatoires. Les auteurs proposent une conduite pratique devant la découverte d’un souffle systolique chez un patient jeune asymptomatique. Conclusion Le médecin d’unité semble maîtriser la séméiologie du souffle organique. Ce constat plaide en faveur de la promotion d’un examen clinique holistique afin de ne pas systématiser le recours à l’échocardiographie tant en termes d’économie de santé qu’en termes de valorisation de l’expertise médicale. The finding of a systolic heart murmur is common in medical military practice. Albeit often benign among young healthy adults, it can reveal a valvular or a cardiac disease, which could worsen during workout or expose to risk of a sudden death. This study aims to evaluate the diagnostic efficiency of the military general practitioner when discovering a systolic murmur among young asymptomatic patients. Materials and methods During one year, this study involved all the general practitioners of the medical military centres of Brittany and the cardiologists of the military hospital in Brest. It prospectively enrolled a cohort of all military asymptomatic patients under 40, without any underlying known heart condition. Military general practitioners listed, thanks to an anonymous form, the main features of the systolic murmur and of the ECG and proposed an auscultatory diagnosis: innocent or organic murmur. Then cardiologists did the same and finally performed a transthoracic echocardiography giving the diagnosis. Results Fifty-eight patients were referred, 5 not meeting the inclusion criteria. Of the 53 patients included, military general practitioners found 46 innocent murmurs and 7 organic ones. Cardiologists found 51 innocent murmurs and 2 organic. Transthoracic echocardiography just took on one organic murmur (linked with a bicuspid aortic valve), spotted by the specialist, though judged innocent by the general practitioner. Discussion Most of innocent murmurs diagnosed by general practitioners (45/46) were confirmed. Regarding the seven organic murmurs, the main selected criteria (intensity over 3, orthostatic persistence, diffuse irradiation) are mostly in accordance with the literature, proving right medical instincts. Authors propose a practical management of systolic murmurs among asymptomatic young patients. Conclusion Military general practitioners seem to master symptoms of organic murmur. This assessment argues for a promotion of a holistic clinical examination, which will help not only to rationalize the use of transthoracic echocardiography in economic terms but also to value the medical expertise. [ABSTRACT FROM AUTHOR]

Résumé Les voies veineuses centrales (VVC) sont essentielles pour l’administration de la nutrition parentérale. Le risque de complications est dépendant de la qualité des soins apportés à la VVC qui influence de ce fait la qualité de vie des patients et le coût des soins. Beaucoup de complications des VVC, infectieuses ou non, peuvent être prévenues par l’existence de protocoles de soins appropriés et standardisés. L’information sur les soins des VVC et les éventuelles complications est essentielle pour le dépistage et le traitement précoce de ces complications ; elle doit faire l’objet de protocoles partagés entre les patients et les soignants. Cet article décrit une évaluation des pratiques professionnelles sous la forme d’un audit clinique destiné à améliorer la qualité de soins des patients en nutrition parentérale porteurs de VVC. Central venous access devices (CVAD) are essential for the administration of parenteral nutrition. The quality of the care of CVAD influences the risk of complications and so the quality of life of the patients and the costs of care. Numerous infectious or non-infectious complications of CVAD can be prevented by appropriate, standardized protocols of care. Information about the care of CVAD and complications is essential for the early recognition and treatment of complications and should be shared between patients and caregivers. This article describes an audit for CAVD care that can be used to improve quality of care in a professional practice evaluation program. [ABSTRACT FROM AUTHOR]

Background The increased use of new costly antifungal agents has led to a considerable increase in pharmaceutical expenditure. In December 2011, the Lorraine Regional Health Agency commissioned the Antibiolor network to evaluate costly antifungal agent stewardship using as reference regional, French, and international recommendations. Methods We performed a regional retrospective multicenter study. The criteria for evaluation were the appropriateness of the indication for treatment, the choice of the agent or of a combination, compliance with dose and treatment duration, and the absence of any alternative. Results One hundred and fourteen prescriptions were analyzed, in 7 intensive care units, 4 hematology units, and 1 infectious diseases unit. The indication for costly antifungal treatment was appropriate in 110 cases (96.5%), the choice of the antifungal agent in 102 cases (93%), the dose in 98 cases (89%), treatment duration in 102 cases (93%), and an alternative antifungal treatment was possible in 10 cases (9%). Eighty-two prescriptions (74.5%) complied with the marketing authorization, 19 (17%) were related to a protocol for temporary use, and 9 (8%) were considered as inappropriate. Conclusion Our results show a high rate of appropriate prescriptions. The easily accessible and regularly updated local recommendations probably resulted in the standardization and optimization of costly antifungal agent prescriptions. [ABSTRACT FROM AUTHOR]

Résumé Objectif Recenser à partir du registre RéAC, les arrêts cardiaques extrahospitaliers survenus sur l’agglomération caennaise afin d’étudier l’épidémiologie et d’analyser nos pratiques professionnelles. Type d’étude Étude observationnelle et prospective, monocentrique. Patients et méthodes De mars 2012 à mars 2013, nous avons recensé 151 patients. Les paramètres démographiques, les délais, les thérapeutiques et le devenir des patients ont été analysés à partir des données saisies dans le registre RéAC. Selon le type de variable étudiée, l’analyse statistique a utilisé le test de Mann et Whitney ou du Chi 2 . Résultats Après exclusion de 22 patients (absence de réanimation spécialisée et transport à « cœur arrêté »), 129 arrêts cardiaques ont été analysés : 107 (83 %) d’origine médicale et 22 (17 %) d’origine traumatique. Un témoin direct était présent pour 94 (73 %) d’entre eux. Les gestes élémentaires de survie étaient débutés pour 59 (46 %) des patients et un conseil téléphonique était délivré par le médecin régulateur pour 47 (36 %) d’entre eux. Après une réanimation cardiopulmonaire spécialisée, 74 (57 %) patients sont décédés sur place. Sur les 55 patients arrivés vivants à l’hôpital, 39 (71 %) sont décédés en réanimation et 16 (29 %) sont sortis vivants de l’hôpital, dont 14 (88 %) avec un pronostic neurologique favorable. Conclusion Le registre national RéAC nous a permis d’analyser les données épidémiologiques concernant les arrêts cardiaques dans notre centre. Ce registre nous a également permis de mettre en évidence des axes de prises en charge perfectibles dont il faudra tenir compte pour améliorer nos pratiques professionnelles. Objective Identify from the RéAC registry, out-of-hospital sudden cardiac arrest in Caen and it's suburbs, to study epidemiology and assess our medical practices. Study design Observational, prospective and monocentric study. Patients and methods From March 2012 to March 2013, we identified 151 patients. Demographic parameters, delays until treatment, drugs given and patient outcomes were analyzed from the RéAC data registry. Depending on the variable studied, the statistical analysis used Mann-Whitney or the Chi 2 tests. Results Twenty-two patients were excluded (no resuscitation attempt and patients who were transported to hospital with chest compressions only, in the absence of spontaneous circulation). One hundred and twenty-nine sudden cardiac arrests were analyzed: 107 (83%) with medical origin and 22 (17%) with traumatic origin. Direct witnesses were present for 94 (73%) of them. Basic life support actions were begun for 59 (46%) patients and a telephone advice was issued by the medical response team for 47 (36%) of them. After an advanced life support, 74 (57%) patients died on the spot. Of the 55 patients reaching the hospital alive, 39 (71%) died in the intensive care unit and 16 (29%) were discharged alive from hospital, of whom 14 (88%) with a favorable neurological outcome. Conclusion RéAC national registry has allowed us to analyze epidemiological data on out-of-hospital sudden cardiac arrests in our center. This register has also allowed us to highlight areas for improvement. They should be taken into account to improve our medical practices. [ABSTRACT FROM AUTHOR]

Résumé: La sécurité transfusionnelle concerne toutes les étapes depuis la prescription des examens immuno-hématologiques jusqu’à la réalisation de l’acte transfusionnel. Dans sa décision du 5 novembre 2006 relative aux bonnes pratiques transfusionnelles, l’Afssaps recommande de transfuser les patients pendant les heures ouvrables de l’établissement et de limiter les transfusions la nuit aux seules urgences vitales. Une enquête rétrospective menée au sein de notre établissement a permis d’évaluer la proportion des transfusions réalisées en horaires de garde. L’objectif de cette évaluation des pratiques professionnelles est d’analyser les raisons conduisant à réaliser des transfusions à des horaires tardifs et d’en évaluer la pertinence. [ABSTRACT FROM AUTHOR]

Résumé: Objectifs: Évaluer les pratiques professionnelles des médecins anesthésistes-réanimateurs (AR) concernant la prise en charge périopératoire des patients coronariens en chirurgie non cardiaque et apprécier l’écart par rapport aux recommandations en vigueur. Méthodes: Un auto-questionnaire a été envoyé de juin à septembre 2011, auprès de 5000 AR, représentatifs des AR exerçant en France métropolitaine. Les différents items concernaient : la démographie, l’évaluation préopératoire du risque cardiovasculaire, le recours à un avis cardiologique spécialisé et la modalité, la prise en charge per- et postopératoire de ce type de patient, et enfin leur connaissance des recommandations en vigueur. Résultats: Dans les neuf régions prospectées, 1255 AR ont répondu, soit un taux de réponse de 25 %. Parmi les répondeurs, 73 % étaient des hommes et 38 % travaillaient dans le public ; 70 % travaillaient dans un bloc opératoire commun avec une activité polyvalente. Concernant l’évaluation préopératoire, 85 % des AR adressaient les patients à haut risque à un cardiologue. Dans 16 % des cas seulement, le score de Lee figurait dans le dossier d’anesthésie et avait été utilisé pour évaluer le risque cardiaque en périopératoire. Seulement 61 % des AR prenaient en compte les six facteurs de ce score nécessaires à la bonne évaluation du risque cardiaque. En revanche, 91 % des AR évaluent systématiquement la capacité à l’effort par l’interrogatoire. L’examen préopératoire le plus fréquemment réalisé (49 % des AR répondants) était un ECG chez les patients âgés. Dans 96 % des cas, les bêtabloquants pris habituellement par les patients étaient prescrits lors de la prémédication. Dans 62 % des cas, les AR arrêtaient systématiquement le clopidogrel avant l’intervention chez les patients à risque. En cas d’arrêt, 38 % utilisaient un relais, dont 29 % par héparine de bas poids moléculaire. Sept pour cent des AR envisageaient une revascularisation chez les patients ayant une coronaropathie connue et stable sous traitement. L’étude POISE était connue par 40 % des AR et 18 % estimaient qu’elle avait modifié leur pratique. Vingt et un pour cent des AR réalisaient en préopératoire des réunions pluridisciplinaires pour les patients à risque. Vingt-cinq pour cent des AR disposaient d’algorithmes de prise en charge des patients à risque cardiaque élevé. Soixante-trois pour cent des AR monitoraient le segment ST en peropératoire. En postopératoire, seuls 11 % des AR demandaient systématiquement chez les patients à risque coronarien : un ECG, un dosage de troponine, une surveillance postopératoire, un suivi cardiologique à distance. En cas d’élévation modérée de la troponine, 70 % des AR réalisaient a minima un ECG et/ou une échographie. Conclusion: Cette enquête met en évidence des écarts entre les recommandations concernant la prise en charge périopératoire du patient coronarien en chirurgie non cardiaque en vigueur et la pratique quotidienne des médecins anesthésistes, justifiant des mises à jour régulières de celles-ci. [ABSTRACT FROM AUTHOR]

Résumé: Introduction: L’hémorragie massive reste une cause importante de mortalité dans les pays développés, particulièrement en obstétrique, chez le polytraumatisé et dans les chirurgies majeures. Le facteur VII activé recombinant (rFVIIa) (Novoseven®) a été développé pour le traitement substitutif des hémophiles, mais était actuellement utilisé dans d’autres indications de saignement aigu. L’objectif de cette étude était d’évaluer le respect des critères d’utilisation hors AMM du rFVIIa selon les groupes définis par l’Afssaps, dans les hôpitaux de l’assistance publique à Paris (AP–HP) en 2010. Patients et méthodes: Nous avons rétrospectivement contacté les services d’anesthésie-réanimation des centres ayant une activité en obstétrique, d’accueil de polytraumatisés, de chirurgie cardiaque, hépatique et pédiatrique pour récupérer tous les dossiers d’utilisation hors AMM du rFVIIa en 2010. La qualité de l’indication et de son utilisation a été analysée sur la base des recommandations françaises ou européennes ou selon la littérature existante dans les domaines considérés. Trois catégories de prescriptions ont été établies : conforme, acceptable et non conforme. Résultats: Sur les 59 patients ayant reçu du rFVIIa hors AMM en 2010, 49 prescriptions ont pu être analysées. L’indication et le moment d’administration étaient conformes dans 100 % des prescriptions pour le polytraumatisme et 83 % des prescriptions pour les hémorragies du postpartum. Les critères biologiques étaient remplis dans deux tiers des prescriptions. La prescription a été jugée conforme ou acceptable dans 82 % des cas, toutes indications confondues. Conclusion: Dans la grande majorité des cas, les prescriptions de rFVIIa, utilisé hors AMM à l’AP–HP en 2010, respectaient les recommandations en vigueur. [ABSTRACT FROM AUTHOR]

Résumé: Introduction: Il s’agit d’une évaluation des pratiques professionnelles (EPP) sur l’antibiothérapie dans un service de médecine interne. Matériels et méthodes: Un recueil prospectif sur six mois des prescriptions antibiotiques et leur comparaison avec les recommandations locales et nationales (molécule, dose journalière, modalité d’administration, durée) ont été réalisés. Résultats: Deux cent vingt-sept antibiothérapies ont été recueillies. Par rapport aux recommandations locales, on retrouvait 56 % de schémas totalement respectés (STR) (infections bronchopulmonaires [IBP] : 38 %, urinaires : 88 % et cutanées : 73 %), 33 % de schémas partiellement respectés (SPR) et 11 % de schémas différents (SD). En prenant comme référentiel les recommandations nationales relatives aux IBP, les résultats étaient : STR : 81 % (dont IBP : 80 %), SPR : 16 %, et SD : 3 %. Conclusion: Ce retour sur les prescriptions a permis de mettre en place des actions pérennes d’amélioration des pratiques. Cette démarche anticipe les EPP qui seront nécessaires pour l’accréditation des établissements et souligne l’intérêt de la prise en compte de plusieurs sources de recommandations pour l’interprétation des résultats. [ABSTRACT FROM AUTHOR]

Résumé: Objectifs: Évaluer l’adéquation de nos pratiques avec les recommandations (17e conférence de consensus, SPILF 2008) et identifier les facteurs associés aux délais des principaux temps de prise en charge. Méthodes: Étude rétrospective observationnelle (2009–2011) portant sur les méningites bactériennes aiguës (MBA) de l’adulte. Les données ont été recueillies par questionnaire standardisé à partir des dossiers médicaux et infirmiers. Résultats: Sur 31 MBA admises aux urgences, 29 (93,5 %) y ont reçu ceftriaxone ou céfotaxime. Les indications de corticothérapie et d’imagerie étaient conformes dans 71,0 % et 83,9 % des cas. Les délais médians (IQR) ont été : admission/ponction lombaire (PL), 2h43 (1h09–5h57) ; admission/antibiothérapie, 3h21 (1h34–5h11). La mention de suspicion de méningite dans le courrier d’admission était associée à une PL plus précoce (p =0,01), et une tendance à l’instauration plus rapide de l’antibiothérapie (p =0,05). Conclusions: La mention de suspicion de MBA dans le courrier d’admission est associée à une meilleure prise en charge aux urgences. [ABSTRACT FROM AUTHOR]

Abstract: In 2003, we sought to determine what were the needs of patients prescribed with long-term glucocorticoid therapy in our internal medicine department. Following this inventory, we decided to homogenize the medical practices regarding glucocorticoid prescriptions in our institution. We also set up a therapeutic educational program focused on these prescriptions. This program is based both on individual and collective sessions. Its aims are to improve patients’ autonomy regarding the glucocorticoid therapy and to improve the quality of care. This program has widely favored discussions within the medical team and has contributed to enrich experience and expertise of each of its member. We believe it has improved both the satisfaction of the patients and the medical staff. [Copyright &y& Elsevier]

Au moyen d’une enquête de satisfaction sur les interventions pharmaceutiques ciblant l’ensemble des prescripteurs, il a été réalisé, au centre hospitalier spécialisé de Sevrey (Saône-et-Loire), une évaluation de la pratique de la pharmacie clinique. Tous les prescripteurs paraissent intéressés par la pharmacie clinique. D’après eux, le pharmacien a certes un rôle d’information sur le bon usage du médicament et sur la détection d’interactions médicamenteuses, mais n’intervient pas dans le choix thérapeutique. Ces conclusions ont conduit à l’élaboration d’un plan d’actions d’améliorations. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To assess, a year after the deployment of the check-list in the centre hospitalier Lyon Sud (CHLS – HCL), the perception of medical and nursing staff regarding the advantages of the check-list and its level of integration within the overall organization of the operating room. Type of study: Descriptive study, questionnaires and audits. Materials and methods: Distribution of individual questionnaires to the entire operating room staff, and observational audits in the operating room, to objectively assess the quality of implementation of the check-list (level II of the HAS – French National Autority of Health). Results: The medical and nursing staff participated equally in using the check-list. This was derived from the individual questionnaires and reinforced by the observational audit; they also revealed an uneven implementation of the three phases, with phase 3 almost never performed. In two-third of the cases, the time-out requirements did not comply with HAS instructions. Nurses and physicians perceived the check-list differently. Even though they agreed that the check-list should be a team effort and is useful, nurses noted a lack of investment and leadership from doctors, in addition to communication problems, which led to a feeling of disrespect towards them when they play the role of the check-list coordinator. Conclusion: The questionnaire and the audit of practice showed strong adherence to the concept in that the surgical check-list was considered useful by all staff. However, it was also considered to be an added formality and its full implementation was rare in practice. There was a problem of distribution and acceptance of roles with nurses often observing that they were the only ones strictly following the check-list due to a lack of medical investment. [Copyright &y& Elsevier]

Abstract: Objectives: To reduce the episiotomy rates, according to the Clinical Practice Guidelines, of 2005, from the French College of Obstetricians and Gynaecologists. Patients and methods: A cross sectional study was conducted, in the university hospital maternities (Maternity 1 and 2) with a retrospective record from medical files. Patients who had delivered in those maternities, by vaginal route, after 22 weeks amenorrhea were eligible. The global rate of episiotomy was analysed from 2006 to 2008. A descriptive clinical study was performed with a retrospective analysis (from July to December 2005 on 100 medical files and from July to December 2007 on 85 files). Besides, a study of episiotomy rate was conducted from 2006 to 2008. Improvement actions were developed between the two phases of assessment of the audit: sharing and comparing the results to standardized episiotomy rates, and elaborating an informatized regional perinatality file with episiotomy related items and national recommendations. Results: Episiotomy rate decreased during the study, from 22.35% in 2005 to 19.34% in 2008, in the Ward 1 (p <0.0001) and from 33.62% in 2005 to 17.93% en 2008 (p <0.0001) in the Ward 2. An improvement was observed between the two periods of audits, for each item of the chart but without statistical signification. Discussion and conclusion: Theses procedures have led to a positive impact on practices thanks to the work group and because of the politics of the perinatal network in favour of an episiotomy reduction. We hope these results could be improved in the future. [Copyright &y& Elsevier]

Abstract: Objectives: Leonetti Law of 2005 concerns procedures for questioning about the appropriateness of initiating or maintaining life-sustaining treatments. Decision of withdrawing and withholding treatment has long been practiced by neonatologists, adult and pediatricians intensivists. In this regard, the recommendations of societies encourage medical teams to assess their practices to improve them. Our evaluation is based on the document of the Ethics Committee of SRLF edited in 2010. Type of study: We achieved a retrospective evaluation of professional practices of the transcription of our decisions of withdrawing and withholding treatment. Patients and methods: This study included all children (95 patients) who have had a questioning about life-sustaining treatment of ICU between March 2008 and August 2011 in the pediatric intensive care unit of Children''s Hospital of Lyon. Our evaluation is based on the document of the Ethics Committee of French Society of intensive care (SRLF) edited in 2010. We collected epidemiological data on children concerned by questioning about the appropriateness of initiating or maintaining LST and an evaluation of the transcription of our procedures for LST in our folders. Evaluation included 40 cases: 20 folders randomly selected prior an information meeting (January 2011) which were compared with 20 cases occurred consecutively after this information. This meeting was intended to remind recommendations of good practice and principal points of the law. The main assessment measure was the improvement of the practices respecting criteria of the document of the Ethics Committee of SRLF modified for pediatric care. Main results: Epidemiological data on procedures are comparable to literature data. Concerning the evaluation of our practices before/after a briefing and highlighted a tendency to the improvement without statistically significance. The transcription of reflection and the arguments of decision of withdrawing and withholding treatment and evaluation of pain was the points who need improvement. Finally, despite the positive developments in the therapeutic use of analgesics and sedatives, pain continues to be undervalued. Conclusion: The evaluation of professional practices is recommended to improve the procedures of questioning about life-sustaining treatments have become an area of expertise in intensive care. [Copyright &y& Elsevier]

Abstract: Objective: Observational study relating to the inscriptions with universitary diplomas (DU) in relation with anesthesiology and intensive care during the year 2010–2011. We had in mind to know the profile and the motivations of the students concerned. Method: A questionnaire was put on line and the registered students with the various diplomas were contacted by e-mail. Different items investigated concerned: demography, type of exercise of the students, heading of diplomas, scientific level of the students, their motivations at the time of the inscription and finally practical organization. Results: We collected 265 questionnaires, that is to say 42 % of answers. The demographic distribution of the registered voters was the followed: 71% of MD, 28% of residents. These doctors exerted for the majority with the public hospital (87%). The inscriptions concerned intensive care diplomas in 90% of the cases. The total scientific level of the students was high, since 46% of them had a diploma other than their medicine thesis. The students were registered for the majority of them “to widen their field of competence” (65%) or “in complement of their initial training” (46%). The other reasons were: “to make up a deficit of their initial training (26%)”, “as continuous medical training” (16%) and finally “for the university validation of an asset” (10%). The rate of total satisfaction of the diplomas was very high (96%). Financial aid was assumed by the institution for 46% of students. Residents were less financially helped than senior practitioners. The overall costs of the DU/DIU, including the registration fee, transport and lodging, were important (>500 euros in 61% of the cases). Conclusion: DUs related to our specialty are much appreciated. They interest a majority of senior doctors, but also a considerable number of residents, which poses the problem of the place of these additional trainings within the framework of initial training. The principal motivations of the registered voters are to supplement their initial training or to widen their field of competence, much more than to make up a deficit of this initial training. Lastly, the total financial expenses associated with these diplomas remain important and appear inversely proportional to the incomes of the registered students. [Copyright &y& Elsevier]

Abstract: Introduction: The excessive and inappropriate use of carbapenems is responsible for the development of resistance. The scientific community has been requiring caution and using these agents in specific cases only. Objectives: The authors had for aim to evaluate the appropriate use of carbapenems in a French university hospital. Design: A retrospective survey was made over two months as a clinical audit to assess professional practices. The evaluation criteria for this audit were: the appropriateness of the indication, the possibility of alternative therapeutic strategies, the choice of an antibiotic combination, duration of treatment and dosage. Results: During the audit period, 103 carbapenem prescriptions were included. Ninety-nine cases were analyzed. Among the carbapenem prescriptions, 28.3% (28/99) did not meet the criterion “appropriateness of the indication”. Carbapenems were mostly prescribed empirically (60/99 [60%]) and most often for lung infections or nosocomial urinary tract infections. Finally, 66.7% (66/99) of all prescriptions were considered inappropriate for at least one criterion. The rate of inappropriateness ranged around 30% for each criterion. Conclusions: This study allowed us to assess professional practices for carbapenem prescriptions. The overall rate of inappropriateness was quite important. Carbapenems were not always used appropriately. These findings highlight the need of new regional guidelines and regular updating of local best practices recommendations. Finally, a stricter validation of carbapenem prescriptions will be implemented at the hospital pharmacy level. [Copyright &y& Elsevier]

Abstract: The medical dashboard (DB) recording our clinical practices indicated on one hand the use of two different diagnosis terms, acute dermohypodermitis (ADH) or cellulitis, and on the other hand, an important antibiotic prescription heterogeneity. Our aim was to define these two diagnosis groups and to document compliance to our antibiotic therapy protocol. Method: ADH and cellulitis were selected in our medical DB that records all patient data. Our local antibiotic therapy protocol was designed in April 2009; the prescription of recommended antibiotic agents defined the compliance to recommendations. The patient files indicating non-consensual therapy were analyzed to determine the reasons for inappropriate prescription. Results: Three hundred and four cases of ADH and 82 of cellulitis were diagnosed over 6.5years. ADH was associated with older age (P =0.007), a higher frequency of venous insufficiency (P =0.015), a lower frequency of cancer (P =0.007), and was more often located on lower limbs (P <0.001), compared to cellulitis. The diagnosis of ADH was associated with higher compliance to our antibiotic therapy protocol, compared to cellulitis: 68% versus (vs.) 24%, P <0.001, and after April 2009: 53% vs. 64%, P =0.033. Among the 162 inappropriate antibiotic prescriptions (42%), 75 were deemed justified after analyzing the patient file, but less frequently for ADH compared to cellulitis: 49% vs. 11,5%, P <0.001. Conclusion: ADH presents different clinical characteristics compared to cellulitis. The antibiotic therapy protocol for ADH cannot be applied to cellulitis. [Copyright &y& Elsevier]

Abstract: In France, continuing medical education (CME) and professional practice evaluation (PPE) became mandatory by law in July 2009 for all health professionnals. Recently published decrees led to the creation of national specialty councils to implement this organizational device. For radiation oncology, this council includes the French Society for Radiation Oncology (SFRO), the National Radiation Oncology Syndicate (SNRO) and the Association for Continuing Medical Education in Radiation Oncology (AFCOR). The Radiation Oncology National Council will propose a set of programs including CME and PPE, professional thesaurus, labels for CME actions consistent with national requirements, and will organize expertise for public instances. AFCOR remains the primary for CME, but each practitioner can freely choose an organisation for CME, provided that it is certified by the independent scientific commission. The National Order for physicians is the control authority. Radiation oncology has already a strong tradition of independent CME that will continue through this major reform. [Copyright &y& Elsevier]

Abstract: Objective: To estimate the morbidity and mortality conferences (MMC) impact in intensive care unit (ICU) setting on quality of care and patients’ safety. Data sources: A review of English and French articles in Medline database (1990–2011) related to MMC in the ICU. Keywords used: “morbidity (and) mortality conference(s)”, “intensive care unit”, “intensive/critical care medicine”. Additional studies identified by hand search in French national guidelines about MMCs and in the Annales Françaises d’Anesthésie Réanimation and Réanimation journals index. Identification and preliminary analysis performed using title and abstract, for every study related to MMC in the ICU. Study selection: Only original studies about MMC in the ICU setting that reported an assessment were included. Papers reporting guidelines and methods for MMC implementation were excluded. Data extraction: Extraction used predefined data fields, including study design, MMC characteristics, assessment methods and results. Data synthesis: Studies about MMC in the ICU are recent and scarce. Results comparison and synthesis are impaired by discrepancies in study designs. Although the effectiveness of MMC is not evidence-based, data are consistent for their positive impact on quality of care and patient safety in the ICU. Conclusion: Further studies are required to assess the impact of MMC in the ICU. Based on this literature review, a 4-level evaluation scheme can be suggested: 1) evaluation of MMC implementation in care units and facilities; 2) evaluation of MMC organization; 3) evaluation of MMC on quality of care; 4) evaluation of MMC impact on patients’ mortality and morbidity. [Copyright &y& Elsevier]

Abstract: Introduction: Fluid therapy is one of the major elements of severe sepsis and septic shock management. A systematic initial fluid bolus is recommended before evaluation of left ventricular filling pressure by the use of indicators of fluid responsiveness, preferentially dynamic ones. A massive fluid therapy could be damaging for the patient. Dynamic indicators of fluid responsiveness are not often relevant in the emergency department. This study was aimed to evaluate the use of indicators of fluid responsiveness by emergency practitioners during septic shock management. Study design: Cross sectional survey using anonymous self-questionnaire. Methods: We included all practitioners working in public emergency department of Languedoc-Roussillon (France). Primary-end point was the use of one indicator of fluid responsiveness at least. Uni- and multivariate analysis was conducted to find associated factors. Results: Of 232 practitioners included, we collected 149 questionnaires (response rate=64%). Hundred and eight practitioners (72% [64–79%]) used at least one indicator of fluid responsiveness. Fifty-six practitioners (38% [30–46%]) used echocardiography, 54 practitioners (36% [29–44%]) used blood lactate concentration, 45 practitioners (30% [23–38%]) used passive leg raising. The use of indicators of fluid responsiveness is associated with easy access to echography device (odd ratio=2.94 [1.16–7.62], P =0.03). Conclusion: Emergency practitioners use preferentially less invasive and less time-consuming indicators of fluid responsiveness. [Copyright &y& Elsevier]

Résumé: Objectifs: Décrire et évaluer la faisabilité d’un processus original d’évaluation des pratiques professionnelles, mis en œuvre lors d’une formation professionnelle annuelle dénommée « Rencontres d’experts en rhumatologie ». Méthodes: Celui-ci, fondé sur une approche pédagogique nouvelle, le test de concordance de script, associée à la revue actualisée de la littérature, permet d’évaluer les pratiques, in vitro, en analysant les « zones d’incertitude » rencontrées dans des recommandations, ici, celles de la Haute Autorité de santé consacrées à la polyarthrite rhumatoïde. Après sélection de ces « zones d’incertitude » par un Conseil scientifique universitaire, environ 80 rhumatologues libéraux et hospitaliers sont interrogés sur des vignettes cliniques élaborées, conformément à la technique du test de concordance de script, et portant sur des situations équivoques. Une revue actualisée de la littérature concernant les sujets abordés est alors présentée et discutée. Puis, les participants à cette formation sont à nouveau interrogés sur ces mêmes vignettes. L’impact de cette revue de la littérature/discussion est enfin mesuré. Résultats: Cette approche originale, jamais utilisée pour évaluer les pratiques professionnelles, s’est avérée faisable et bien acceptée par des rhumatologues libéraux et hospitaliers, comme l’atteste le bon niveau de satisfaction. Discussion: Cette première expérience positive incite à utiliser cet outil à une plus grande échelle pour l’évaluation des pratiques professionnelles. [Copyright &y& Elsevier]

Abstract: Objectives: To assess physician compliance with guidelines for surgical antimicrobial prophylaxis practices and to identify factors associated with non-compliance. Patients and method: In a prospective study of patients admitted for clean or clean contaminated surgery from February 1 to April 28, 2008, we assessed appropriateness of surgical antimicrobial prophylaxis indication (recommended and prescribed or not recommended and not prescribed) and administration (antimicrobial choice, dose, timing and duration). Overall compliance was achieved if all criteria of indication and administration were met. The overall non-compliance rate was estimated and was used as a dependent variable in a multivariate logistic regression analysis to identify factors associated with non-compliance. Results: In a total of 481 practices evaluated, appropriateness of indication and administration of surgical prophylaxis were respectively 83% and 56%. The overall compliance rate to guidelines for surgical antimicrobial prophylaxis was 37%. In a multivariate regression analysis, prescription of antimicrobial prophylaxis by a surgeon (RR: 3.4; CI 95%: 1.6–7.5), clean-contaminated surgery (RR: 2.2; CI 95%: 1.4–3.7), traumatology surgery (1.87; 1.1–3.3), digestive surgery (3.7; 1.8–7.5) and head or neck-related surgery (11.4; 2.3–56.3) were independent factors associated with non-compliance to guidelines for surgical antimicrobial prophylaxis. Conclusion: This study confirmed previous findings on the impact of the type of surgery and the wound class contamination on the overall compliance rate. Furthermore, non-compliance was related to surgeon prescriptions. The compliance should be improved by specific measures after professional feedback. [Copyright &y& Elsevier]

Abstract: Objective: To improve the quality of proton pump inhibitors (PPI) prescription in an orthopaedic department. Study design: Prospective professional practice evaluation study. Patients and methods: A specific protocol concerning the best practice for using PPI in the perioperative period was established by anaesthesiologists and validated by all prescribers, according to recent recommendations published by French Afssaps. PPI prescription pertinence, mainly using the oral route, was based upon the presence of clearly identified risk factors. PPI mensual consumption and severe gastric complications were analyzed and compared with those obtained from the previous year. Ten months after the beginning of the protocol, the pertinence of PPI prescription was analyzed in 20 randomly selected medical records. Data are expressed in defined daily dose (DDD). Results: After one year, a 35.5% decrease in oral PPI consumption was noted (901±211 before vs 581±235 DDD, after, P <0.05). A similar trend to a decrease in intravenous PPI consumption was observed (40±23 vs 22±26, P =0.06). During the same period, the overall incidence of severe gastric complication remained stable. The PPI prescription was pertinent in 85% of selected medical records. Conclusion: This study confirmed the interest of professional practice evaluation protocols to improve PPI prescription. A strong implication of all medical staff members is mandatory to maintain such benefits over time. [Copyright &y& Elsevier]

Abstract: Objective: Improving the use of antimicrobial drugs is a national objective. To this end an evaluation of clinical practice was implemented on prescribed antibiotics in elderly patients, in the Besançon Teaching Hospital. Design: In 2005, a clinical audit compared the adequacy of antibiotic prescriptions to national guidelines in 37 patients. An improvement plan was implemented, including the drafting of local guidelines (adapted national guidelines) “Antibiotic prescription in elderly patients” by a multidisciplinary team. The Antibiotics Committee approved it. A retrospective study compared antibiotic prescription of 62 patients to these guidelines. The methodology was based on Gyssen''s algorithm. The assessment criteria were: relevance of the indication, absence of a better alternative, respect of recommended dose, duration, and timing. Results: The rate of overall conformity was 26% in 2005, 57% in 2007. Antibiotic choice was adequate in 61% of cases in 2005, 78% in 2007. In 63% of cases, a more efficient alternative was advised in 2005, 10% of cases in 2007. Treatment duration, dose, and timing were adequate in 54 – 92 – 96% in 2005 respectively and 86 – 92 – 100% of cases in 2007. Ciprofloxacin was prescribed in first line for 42% of urinary infections in 2005, 0% in 2007. Conclusions: This approach improved antibiotic prescriptions because of better guideline observance by physicians. The main improvement concerned fluoroquinolones. It should be continued to confirm antibiotic good use and protect our hospital bacterial ecology. [Copyright &y& Elsevier]

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Abstract: Objectives: The objective was to evaluate the good use of fluoroquinolones in a hospital with a relevance review in the context of an approach to evaluation of professional practices at the regional level initiated by the Antibiolor network. Method: In February 2008, in each volunteer service, practitioners filled out a standardized form indicating indication, the name of the fluoroquinolone, route of administration and duration of treatment, retrospectively from 20 medical records on the last 3 months. Each one was analyzed by a binomial (doctors and pharmacists) according to the local Antibioguide. The degree of compliance requirements has been appreciated by a global index of adequacy of therapeutic consisting of six criteria. Results: Eighteen units of Nancy''s hospital filled 475 cards. The most frequent indications were pulmonary infections (38 %; 181/475) and urinary (23 %; 111/475). The fluoroquinolone indication was non-conform for 28 % of the cards (133/475). When the fluoroquinolone indication was justified, the association with another antibiotic was considered non-compliant in 20 % of cases (70/342), the choice of the molecule in 18 % (62/342), duration of treatment in 17 % (57/342), the dose in 13 % (45/342) and route of administration in 9 % (30/342). The requirements were entirely conform in 34 % of cases (160/475). Conclusion: The results were communicated to each participating service with corrective actions and then this experience has been repeated in May 2009. [Copyright &y& Elsevier]

Summary: Objective: The mortality and morbidity conference (MMC) is one of the keystones in the evaluation of quality of care. The objective of this work was to describe a MMC by presenting a case report. Case report: A 16-year old man suffering from chronic anaemia had to be transfused with two units of red blood cells in an outpatient unit. Although the transfusion went well for the first unit, the patient presented haemolysis during the transfusion of the second unit because the nurse administered the wrong unit. The incident was analysed during a mortality and morbidity conference with the attendance of the hemovigilance local correspondent. Immediate causes of the event were the failure to respect the transfusion procedure: in advance compatibility testing, failure to check the patient and blood component identification just before the transfusion. Factors contributing to the event were the deviation of transfusion practices, poor working conditions of nurses, linked to inadequate staff in relation to the activity. The discussion of the incident led to develop an action plan. Discussion: This case shows the interest for staff members to discuss an adverse event. However, a well-defined methodology for conducting mortality and morbidity conferences is lacking and leads to a wide heterogeneity between teams. Major differences refer to criteria for case selection and quality of participants. This heterogeneity is likely to have an impact of the efficacy of mortality and morbidity conferences regarding the quality and safety of care. [ABSTRACT FROM AUTHOR]

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Abstract: The evaluation of clinical practice includes three successive phases: demonstration of suboptimal clinical practice, proposals for improvement, and assessment of effective changes. We present a medical computerized database used for this evaluation. Patient and methods: Our database includes 24 parameters for all hospitalized patients among which diagnosis and antibiotherapy. The first assessment phase indicated an unjustified heterogeneous antibiotherapy for community-acquired pneumonia (CAP). The second phase was the drafting of our own consensus for CAP treatment, aiming at reducing the use of fluoroquinolones and third generation cephalosporin. The computerized database was used in the third phase to check observance of our consensus. Results: Two hundred and fifty patients were hospitalized for CAP before the consensus, from October to January 2005, 2006, and 2007, compared to 113 patients from October 2008 to March 2009. The rate of adequate prescriptions improved from the first period to the second one: 58% versus 69%, p =0.045. The inadequate use of fluoroquinolones and third generation cephalosporins was more frequent during the first period, compared to the second one: 49% versus 38%, p =0.048. The mean hospital stay was longer before applying our consensus: 9±5 days versus 7±4 days, p =0.009. Evolution was unfavorable in 15/250 cases (6%) and 3/113 cases (<1%), respectively. Conclusion: A medical database allows for a rapid implementation of two out of three phases of clinical evaluation, through the appropriation of a new consensus, with a reduction of antibiotic misuse without impact on infectious morbidity and mortality. [Copyright &y& Elsevier]

Summary: Hemapheresis is made up of a set of essential methods for modern medical practices. Applicated to donors, they allow production of labile blood products as well as raw material for plasma products industrial manufacturing; applicated to patients, they are indispensable for the treatment of many pathologies. Conditions for their implementation are very variable according to the teams who have few tools at their disposal to access, standardize and make reliable their activity. Therefore, an approach has been initiated by the Institut National de la Transfusion Sanguine and the Hemapheresis French Society to develop a guide which primary goal is to help teams evaluate themselves in different areas of their responsabilities. The generalization of the evaluation of professional practices in all activities and specialities required recently by the third iteration of the certification procedure of health institutions and a new law about French health system reinforce us in our approach. Finally, hemapheresis is not whithout risks, neither for donors nor for patients, which now encourages us to analyze sharply our procedures, to identify risk situations and develop means of prevention. This second step is already a current news for us. [ABSTRACT FROM AUTHOR]

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Summary: Background: The 2000 French Consensus Conference for Acute Viral Bronchiolitis management underlined clinical practice recommendations. Objective: To assess the impact of these guidelines on management of acute bronchiolitis, 3 and 8 years after publication. Methods: A standardized questionnaire was mailed to 762 general practitioners (GPs) in 2003 and 800 GPs in 2008. It described two clinical case scenarios (moderate acute viral bronchiolitis and severe acute bronchiolitis) and inquired about the physician''s conduct in each case. The primary outcome was the percentage of responders who described patient management in accordance with current guidelines: correct diagnosis and treating the patient symptomatically in an outpatient setting in the first case and correct diagnosis in addition to requiring an inpatient setting for the second case. Secondary outcome was the percentage of responders who would have given unnecessary or potentially harmful treatments. Physician responses in 2003 and 2008 were compared using the Student t-test and the Chi2 test. Multivariate analysis was conducted to assess the potential factors associated with good adherence to guidelines. Results: Nearly 25% of the questionnaires were returned in 2003 and 2008. Patient management was described in accordance with the guidelines in only 6% in 2003 and 20% in 2008 (p ≤0.001). Unnecessary treatments were prescribed in 77% in 2003 vs 60% in 2008 (p <0.001) and potentially dangerous treatments in 38% in 2003 vs 22 % in 2008 (p =0.006). Using multivariate analysis, the GP''s age was inversely correlated with adherence to clinical recommendations (adjusted odds ratio [adOR]=0.93; 95% CI=0.87–0.98; p =0.01). Fifty-four percent of GPs reported knowing these guidelines, but only 57% of them declared that the latter has modified their practice. Discussion: GPs are still prescribing unnecessary or even potentially dangerous treatments for bronchiolitis. On the other hand, severe cases are correctly diagnosed and well managed in an inpatient setting. Conclusion: Three and 8 years after their publication, adherence to guidelines is insufficient. [Copyright &y& Elsevier]

Abstract: Introduction: Methods used for the assessment of professional practices must be dependable and reproducible. The aim of this study was to assess a method used in our hospital to assess antibiotic therapy for acute community-acquired pneumonia (CAP). Method: In this study, a pharmacist and two infectious disease specialists retrospectively and independently evaluated the compliance to local antibiotic guidelines for 124 patients. The assessment tool was a Medical Appropriateness Index (MAI) (nine items). The kappa agreement index (K) among experts was calculated. Results: The agreement among experts was poor for the initial antibiotic treatment (K =0.16) and route of administration (K =0.14), low for the duration of treatment (K =0.34), and null for the dose and adjustment to 72hours. Conclusion: Differences between experts can be explained by the complexity of medical records, the number of items assessed, the complexity of the MAI, but also by the specialization and experience of experts. Thus, the assessment of CAP antibiotic therapy requires the use of appropriate methods targeting reliable criteria. [Copyright &y& Elsevier]

À partir des principes de la formation médicale continue (FMC) et de l’évaluation des pratiques professionnelles (EPP) en vigueur, les rapporteurs de l’Inspection générale des affaires sociales (Pierre-Louis Bras et Gilles Duhamel) proposent un nouveau concept : le développement professionnel continu. [Copyright &y& Elsevier]

Abstract: Purpose: Quinolones are widely prescribed in various hospital departments (about 20% of antibiotics prescriptions in some of them) and antibiotic resistances is increasingly documented. The aim of this prospective study was to assess the prescriptions of quinolones in several departments of medicine of Rouen University Hospital and compare them to the guidelines of good medical practice for antibiotic prescriptions. Methods: This study was performed in four medicine departments during two months. When a physician prescribed a quinolone treatment, he had to record informations regarding the infection (type and site, bacteriological proof or not), the patient (age, sex and glomerular filtration rate) and the prescription of quinolone (indication, dosage, administration, combination with another antibiotic, duration of treatment). Results: A hundred and three prescriptions of quinolones were analysed (mean age 75±0.5 years). Quinolones treatments were more often used alone, in first intention and without bacteriological proof. The dosage of quinolones was generally adapted but the duration of treatment was often excessive. Quinolones prescriptions were in majority in accordance with the guidelines for pulmonary infections, but were more often inappropriate for urinary infections. Conclusion: According to the infections, this study shows discrepancies with the published guidelines with respect to prescription of quinolones, but there are also differences between available guidelines that may at least in part explain our results. An harmonization and a large diffusion of uniform guidelines could improve patients antibiotherapy. [Copyright &y& Elsevier]

Abstract: The haemovigilance unit decided to set up since 2003 an evaluation of professional practices of blood transfusion chain from the prescription of blood products to the transfusion act and follow-up of receivers in several health care services. We have founded that the medical and nurse dysfunctions are the same in all cases. We have decided to analyze the causes of these dysfunctions and to propose actions to perform practices using a ¿problem-solving system model¿. We followed the next stages: (1) characterization of the problem in ¿QQOQCCP¿ form (What? Who? Where? When? How? How many? Why?), (2) analysis of the causes presented in Ishikawa''s cause-and-effect diagram form and (3) search and selection of solutions of improvements. [Copyright &y& Elsevier]

Abstract: Objectives: Since the last national survey on evaluation of professional practice in France, many peripheral nerve blocks techniques were developed. The aim of this study was to assess the place of such techniques and their impact on the stay in recovery room after orthopaedic surgery. Study design: Prospective, multicentric study. Patients and methods: Consecutive patients receiving a regional anaesthetic technique for orthopaedic surgery over a 15-day period were included in this multicenter study (four private clinics, two non-university and three university hospitals). Characteristics of blocks, duration of stay and activity of nurses in post-anaesthetic care unit (PACU) were recorded for each patient. Results: A total of 289 blocks performed in 283 patients were analyzed. A regional anaesthetic technique was performed alone or associated with a light sedation (58 and 8% respectively) or with a general anaesthesia (44%). A continuous peripheral nerve block (mainly for femoral and iliofascial blocks) was performed in 25% of patients, mostly in university hospital and private clinics (35 and 26% respectively), but only in 3% of cases in non-university hospital. Mean duration of PACU stay was 64±67 minutes. This time was longer when regional anaesthesia was associated to or performed after general anaesthesia. Workload of nurses was a simple supervision in 47% of the cases (in 61% of patients receiving regional anaesthesia alone vs 21% in those with general anaesthesia, p <0.05). Conclusion: This survey confirms that peripheral nerve block became widely used in orthopaedic surgery. This decreases the medical workload in PACU, especially for distal upper limb surgery. Regional anaesthetic techniques must be well taught during formation cursus of residents. [Copyright &y& Elsevier]

Abstract: The evaluation of the professional practices (EPP) is obligatory for all the physicians since July 1, 2005 for a first five-year period. It represents one of the components of the continuous medical training (CMT). The French Society of Blood Transfusion and National Institute of Blood Transfusion are the promoters of the EPP in transfusion technology and medicine. Initially, the programs of EPP will be conceived and controlled by experts and will relate to their basic activities. During a five years cycle, the physician taking part in a program must validate a specific action and take part in a rolling programme. At the end of the programme, the physician will receive a certificate issued by National Institute of Blood Transfusion and will have to submit it to a committee placed under the responsibility of the regional physicians’ committee. [Copyright &y& Elsevier]

Abstract: Objectives: To evaluate the impact of difficult intubation workshops on airway management knowledge and daily medical practice in anaesthesiology. Study design: Prospective survey. Methods: The participants to the workshops accredited by the French college of anaesthesiologists (Cfar) in 2003 were invited to answer to MCQ before, immediately and three months after the course. They also completed a questionnaire provided during the workshop and three months later, focusing on medical practice and their own organization in the area of difficult intubation before and after the workshop. Results: One hundred (and) seven participants responded to the immediate evaluation (MCQ and questionnaire) whereas 32 responded to the delayed evaluation performed three months later. A subjective scale was used to assess the level of knowledge in difficult intubation (0: lowest level, 10 highest level).The mean score for subjective knowledge considering difficult intubation was 4.7±2.3 before the course and 6.9±1.6 at 3 months (P <0.001). The mean scores attributed to MCQ were not different before and after the workshops. Participants expected complementary practical training (65%) and theoretical courses (40%). Delayed evaluation revealed that 25/32 participants had to deal with difficult intubation during their clinical practice after the workshop, but 3 cases (12%) could not be managed with success. Defects could be observed in terms of organization: no difficult airway trolley (22%), no predefined difficult airway algorithm (66%), and information: no written information given to the difficult airway patient (44%), and no information given to the difficult airway patient''s home doctor (91%). Discussion: These results showed that difficult intubation remains a real problem for anaesthesiologists. They also revealed differences between subjective and objective knowledge and pointed out defects in terms of organization and management which should be improved. [Copyright &y& Elsevier]

Abstract: Management of septic shock requires complex and multiple diagnostic as well as therapeutic procedures in a limited time-frame. This issue is a major source of medical errors. The author presents a critical analysis of tools (guidelines, clinical path, algorithm, check-lists) to help physicians for the management of patients with septic shock. [Copyright &y& Elsevier]

Abstract: Objectives: Imogam rage® (IgR) prescriptions were assessed in the rabies prophylaxis centre of Poitiers (France). Material and methods: All medical records closed between January 1 and June 1, 2005 were retrospectively analyzed. An infectious disease specialist examined the pertinence of IgR prescription according to WHO references adapted to the epidemiological situation by the Pasteur Institute French rabies center. The indicator used was the proportion of patients treated by IgR among all patients treated by vaccination or vaccination with IgR. Results: During the study period, 69 medical records have bewereen analyzed: 48 (70%) patients were treated including 22 (46%) with IgR. Imogam rage® indication was not appropriate for 21 (95%) patients (one contact with a rodent, 8 low gravity contact, 12 contacts with a French animal) that is to say 86 IgR® vials. The direct cost was 8,032 euros. Conclusion: This assessment permitted to underline an overprescription of IgR®, to adapt guidelines to the local situation, and to improve care quality by adaptating medical record files, improving the prescription decisional tree and the local guidelines, and improving the training of interns. [Copyright &y& Elsevier]

Abstract: Professional recommendations now in use raise the issue of their implementation in the field by health professionals as their relevance to clinical practice. Taking this into account, the Conseil National Professionnel de Psychiatrie-Collège National pour la Qualité des Soins en Psychiatrie (CNPP-CNQSP) developed a recommendation to improve coordination between general practitioners and psychiatrists. Through its working groups on professional practice evaluations, whose work has been formalized in field surveys, the college has proposed methodological innovations from the clinical practice recommendations model. Its purpose is to improve the applicability and feasibility of the recommendations. The present use of this recommendation by practitioners concerning correspondence exchanged between GPs and psychiatrists confirms the major importance for improving practices of these methodological developments proposed by professionals within the framework of the CNPP-CNQSP. [Copyright &y& Elsevier]

Abstract: Clinical practice evaluation programme is now a mandatory process for healthcare institutions. Integrative part of the certification procedures conducted by the French National Health Agency (Haute Autorité de Santé [HAS]), it has became a new major approach to improve both the quality and the safety of healthcare. It concerns also transfusional practices. [ABSTRACT FROM AUTHOR]