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The background and the aim of the work: The Department of Orthopedics and Traumatology of the "Carlo Poma" Hospital (Social Territorial Health Authority of Mantova), has pointed out in 2017, through the questionnaires survey over the citizens satisfaction, an appreciation decrease compared to the previous years. The obtained data were not sufficiently explanatory of the reasons for that kind of deterioration and also not enough specific to define possible corrective measures. The aim of this work was to identify the patients' perception regarding the hospitalization phases (from booking to follow up), taking into account five kind of operations and pathologies: 1st knee, shoulder and tibio-talar arthroscopy; 2nd hip and knee prosthesis; 3rd upper limb traumatology; 4th lower limb traumatology and 5th orthogeriatrics., Methods: The research is based on 29 narrations resulted from orthopedic patients between 30 and 80 days after the time of discharge., Results: The phases of care path which get the highest level of satisfaction are those concerning the operation and the outpatient visit followed by rehabilitation and assistive continuation. The most negative phase was the discharge but, also the needs assistance respond, the reception, the microclimate and the pre-operative medical assessment resulted contradictory. At the same time the three most significant areas of improvement were: the organization (critical for upper limb traumatology, arthroscopy and prosthetics); the health features (critical for the lower limb, orthogeriatrics and traumatology) and medical information (the most critical issues were those concerning the upper limb traumatology while the less were the orthogeriatrics ones)., Conclusion: Use the narration to go into the orthopedic patient needs and perceptions allows to activate appropriate and customized organizational and professional changes in order to answer adequatly to the patient's needs to limit litigation and defence medicine expences.

The purpose of this research is to identify and formalize the Hospital Hygiene Service activities and products, evaluating them in a cost accounting management view. The ultimate aim, is to evaluate the financial adverse events prevention impact, in an Hospital Hygiene Service management. A three step methodology based on affinity grouping activities, was employed. This methodology led us to identify 4 action areas, with 23 related productive processes, and 86 available safety packages. Owing to this new methodology, we was able to implement a systematic evaluation of the furnished services.

Background: Hospital is the most common place of cancer death but concerns regarding the quality of end-of-life care remain., Aim: Preliminary assessment of the effectiveness of the Liverpool Care Pathway on the quality of end-of-life care provided to adult cancer patients during their last week of life in hospital., Design: Uncontrolled before-after intervention cluster trial., Settings/participants: The trial was performed within four hospital wards participating in the pilot implementation of the Italian version of the Liverpool Care Pathway programme. All cancer patients who died in the hospital wards 2-4 months before and after the implementation of the Italian version of Liverpool Care Pathway were identified. A total of 2 months after the patient's death, bereaved family members were interviewed using the Toolkit After-Death Family Interview (seven 0-100 scales assessing the quality of end-of-life care) and the Italian version of the Views of Informal Carers - Evaluation of Services (VOICES) (three items assessing pain, breathlessness and nausea-vomiting)., Results: An interview was obtained for 79 family members, 46 (73.0%) before and 33 (68.8%) after implementation of the Italian version of Liverpool Care Pathway. Following Italian version of Liverpool Care Pathway implementation, there was a significant improvement in the mean scores of four Toolkit scales: respect, kindness and dignity (+16.8; 95% confidence interval = 3.6-30.0; p = 0.015); family emotional support (+20.9; 95% confidence interval = 9.6-32.3; p < 0.001); family self-efficacy (+14.3; 95% confidence interval = 0.3-28.2; p = 0.049) and coordination of care (+14.3; 95% confidence interval = 4.2-24.3; p = 0.007). No significant improvement in symptom' control was observed., Conclusions: These results provide the first robust data collected from family members of a preliminary clinically significant improvement, in some aspects, of quality of care after the implementation of the Italian version of Liverpool Care Pathway programme. The poor effect for symptom control suggests areas for further innovation and development.

The Italian Society of Internal Medicine has developed a voluntary program of professional accreditation of the medical units run by its constituency. Participation in the program, which is meant to foster staff involvement in clinical governance, includes all the medical personnel and nurses. Accreditation is awarded provided the candidate unit is able to adhere to a pre-established set of quality standards, meet a number of clinical and organizational requirements and monitor specific indicators. Self-evaluation is the first step in the program, followed by a site visit by a team of peer internists experienced in quality auditing. The program, which has involved so far 19 units, has considered a number of clinical requirements related to the three most frequent diseases in Italian internal medicine wards: chronic heart failure (CHF), exacerbation of chronic obstructive pulmonary disease (COPD) and hepatic cirrhosis with ascites (HCA). The comparison between self- and peer-evaluation witnessed less discrepancies for disease-related than for organizational requirements, the latter being met to a smaller degree by most units. In particular, concordance was higher for requirements and indicators pertaining to CHF and HCA than to COPD. This program of professional accreditation developed by the Italian Society of Internal Medicine has the potential to describe, monitor and improve clinical and organizational performances in internal medicine. It should also be seen as a contribution to implement the strategy of professional governance in hospitals.

Patients with acute renal disease are mostly admitted to the units of internal medicine and nephrology present in the medium-sized hospitals that constitute the bulk of the Italian hospital network. The needs of increasingly elderly patients with chronic conditions and comorbidities warrant a comprehensive approach and continuity of health care along with a high level of specialist expertise. The new models that integrate the specialties within the department of medicine and the new organizational structure of the hospital based on progressive patient care can achieve these objectives by ensuring both the development of the specialties and the overall effectiveness of the system.

Background: The clinical efficacy of multipurpose observation units has not been assessed in comparative studies. A study was undertaken to analyse the effects of the adoption of clear criteria of admission, clinical pathways and time limits together with the strengthening of clinical supervision and dedicated staff on the performance of a short observation unit (SOU)., Methods: In the period from 1 January to 26 March 2007, the rates of SOU utilisation, length of observation, consumption of resources during observation (diagnostic tests and specialist consultations), rates of hospitalisation and adverse events were measured. Reattendances at the emergency department (ED) within 3 months of discharge were also analysed. Patients admitted to the SOU during the same period in 2006 acted as controls., Results: Compared with 2006, more patients were admitted to the SOU from the ED (8.8% vs 4.5%, p<0.01) where they had spent less time (mean (SD) 13.8 (11.6) h vs 23.0 (13.4) h, p<0.01). Despite the reduction in the length of stay, case mix standardised rates of hospitalisation were not significantly increased (28.9% vs 26.2%). Consultations and radiological investigations were reduced (32.4% vs 40.2%, p<0.05; and 34.1% vs 45.3%, p<0.01, respectively). Adverse events during the observation period or after hospitalisation were exceptionally rare. The short observation of intestinal obstruction, upper gastrointestinal bleeding without endoscopy, chronic obstructive pulmonary diseases, pneumonia or acute heart failure gave questionable benefits since they had high rates of hospitalisation. During the 3 months after discharge from the SOU, fewer patients returned to the ED (16.3% vs 27.2% for all causes, p<0.01; 9.3% vs 14.4% for related causes, p<0.05) and hospitalisation was necessary in fewer cases (1.7% vs 4.3% for all causes, p<0.05) while re-admissions to the SOU remained unchanged (8.7% vs 8.2%, p = NS)., Conclusion: Brief observation in the ED draws a clear benefit from proper organisation and the adoption of standardised clinical pathways.

Background: Patients with stroke should have access to a continuum of care from organized stroke units in the acute phase, to appropriate rehabilitation and secondary prevention measures. Moreover to improve the outcomes for acute stroke patients from an organizational perspective, the use of multidisciplinary teams and the delivery of continuous stroke education both to the professionals and to the public, and the implementation of evidence-based stroke care are recommended. Clinical pathways are complex interventions that can be used for this purpose. However in stroke care the use of clinical pathways remains questionable because little prospective controlled data has demonstrated their effectiveness. The purpose of this study is to determine whether clinical pathways could improve the quality of the care provided to the patients affected by stroke in hospital and through the continuum of the care., Methods: Two-arm, cluster-randomized trial with hospitals and rehabilitation long-term care facilities as randomization units. 14 units will be randomized either to arm 1 (clinical pathway) or to arm 2 (no intervention, usual care). The sample will include 238 in each group, this gives a power of 80%, at 5% significance level. The primary outcome measure is 30-days mortality. The impact of the clinical pathways along the continuum of care will also be analyzed by comparing the length of hospital stay, the hospital re-admissions rates, the institutionalization rates after hospital discharge, the patients' dependency levels, and complication rates. The quality of the care provided to the patients will be assessed by monitoring the use of diagnostic and therapeutic procedures during hospital stay and rehabilitation, and by the use of key quality indicators at discharge. The implementation of organized care will be also evaluated., Conclusion: The management of patients affected by stroke involves the expertise of several professionals, which can result in poor coordination or inefficiencies in patient treatment, and clinical pathways can significantly improve the outcomes of these patients. It is proposed that this study will test a new hypothesis and provide evidence of how clinical pathways can work., Trial Registration: ClinicalTrials.gov ID [NCT00673491].

The air in hospital wards with patients at high risk (Surgeries, Intensive Care Units and Bone Marrow Transplant Centers) has been surveyed less than the one in Operating Rooms. Therefore in this study we considered useful to verify the microbic contamination of the air of those wards evaluating the consistency of ventilation systems in relation also to the presence and location of HEPA absolute filters. Seven departments of Genoese San Martino Hospital at high risk of infection were taken into account. In there, environmental investigations have been performed by air samplings and by analyzing bacterial and fungal growth on plates after an incubation period. Almost 60% of all samples taken in wards yielded a positive result and the average values of bacterial and aspergillar charges measured at air flow emission openings decisively exceed the ones considered standard in operating rooms. Still, the average values of airborne bacterial charges were significantly higher in those wards equipped with central filters (p < 0.001), while as far as the aspergillar charge is concerned, no statistically relevant differences were noticed. In wards with ventilation system, the bacterial charge value raises from the emission grids to the middle of the room and to the aspiration grids, while the ward not equipped with a ventilation system presents in the middle of the room an average bacterial charge 2 to 10 times higher than the one in other wards. The average values regarding bacterial and aspergillar charges resulted quite high in all the departments surveyed. Nevertheless, if we take into account ventilation systems equipped with absolute filters HEPA located centrally or peripherally, it can be outlined that the air quality from the point of view of both microbic and aspergillar contamination turns out to be decisively better in systems with peripheral filters. Moreover, a compared analysis of the three Hematology wards allows us to infer that the presence of artificial ventilation systems can lower the bacterial and fungal compared with a ward with natural ventilation.

Stroke unit care represents the major advancement in stroke management and it is applicable to all stroke patients. The Lombardia Health-Care Program for the period 2000-2004 planned to implement new semi-intensive stroke units in order to guarantee access to such units to all stroke patients. As has happened in other countries, there is a need to coordinate and streamline the process of care in order to optimise resources and outcome. The aim of the Stroke Unit Network (SUN) project is the improvement of the quality of stroke care in the acute and post-acute phase, developing an efficient network between hospitals involved in stroke care in order to quickly identify patients' needs and to improve cultural exchange on clinical and therapeutic information between people involved in the process of care. A web-based network has been created connecting the Lombardia Stroke Units and the departments in which stroke units will be implemented; a website to facilitate the exchange of scientific data, the discussion of clinical problems, the sharing of research projects and results, and a web-based quality register in order to verify quality, efficacy and efficiency of stroke units participating in the project providing important, consistently available data to monitor progress in reducing the incidence of stroke and associated disability and mortality. The Lombardia Stroke Unit Network Project, promoting and facilitating the exchange of know-how and collecting data on the quality of the processes of care provided, can significantly improve stroke care in Lombardia.

We explored whether local practice guidelines (PGs) on stroke management had undergone a process of local adaptation in relation to the appropriate and feasible configuration of stroke units (SUs). We critically appraised 7 PGs developed by 6 Italian local healthcare units, using explicit criteria to evaluate internal validity and their adequacy relative to local implementation issues. All PGs were developed by multidisciplinary working groups. In 4 of 6 PGs recommending SUs for stroke care, methodology for evidence retrieval was poor. Although organisational aspects were addressed in 4 of 6 PGs, details on how a SU should be organised were not provided in any of the examined PGs. Despite availability of national and international stroke PGs, at local level guidelines developers seem to spend time in "reinventing the wheel" rather than concentrating on what matters for local implementation. Besides being inefficient, this seems to lead to methodologically poor products inappropriate for what should be done to assure that interventions that work are packaged in a way that is compatible with their uptake into the ongoing services activities.

Objective: to identify and solve problems concerning satisfaction of inpatients in three different vascular surgery units., Materials and Methods: a self-administered non anonymous questionnaire was submitted. Four dimensions of patients' satisfaction and a measure of overall satisfaction were evaluated. For each of them a logistic regression model was elaborated., Results: one hundred and fifty-six eligible patients agreed to participate. For the "overall satisfaction" 56% rated the care received as excellent; patients completely satisfied for "treatment and related information" were 76%; for the "availability of staff" 96%, for "helpfulness and communication by staff" 56% and for "management of patient's complaint by medical staff" 86%. Logistic regression analysis showed, after adjustment for relevant background factors, a statistically significant difference among units of care for the overall satisfaction., Conclusions: the study highlighted the importance of considering in vascular units the patients' satisfaction as an essential component of quality of care independently of the severity of cases. The hospital management recognised the low level of communication by the staff as one of the hospital bottle-necks and tried to solve a logistic problem identified as responsible for a low score in the overall satisfaction in one unit.

This is a critical review of the methodological and motivational aspects of two experiences of adverse event (AE) monitoring using a surveillance diary incorporated into the progress notes of medical records. Methodological aspects of the study were that (1) AE monitoring was to become an everyday activity of ward physicians; (2) the physicians were to express their opinions concerning the causality of each AE, which was to allow the systematic detection of adverse drug reactions and unexplained AEs; (3) the surveillance diary was to include all AEs and all prescriptions, thus allowing prescription-event monitoring; (4) the time trends of unexplained AEs were to be monitored using control cards. The experiences were discontinued because the necessary investments were attributed to other competing priorities. It follows that it is essential to develop an awareness that AE surveillance requires continuous involvement insofar as it is an essential element of quality of care.

Seventy-three environmental and clinical isolates of Pseudomonas aeruginosa recovered from a single hospital over a 6-month period were compared for epidemiological type characteristics. Environmental isolates were obtained from sinks, taps and water, in rooms where patients were treated. The strains represented only six O-antigenic types and 8.2% of them were not typable. Serotype 011 was most frequent in the environment, whereas serotypes 06, 012 and 02,5 predominated among clinical isolates. More than 60% of all isolates belonged to four pyocin types (1, 10, 33 and 45), and approximately 80% were phage typable. Environmental isolates were more sensitive to antibiotics than clinical isolates. There was little correspondence between the types of strains of P. aeruginosa isolated from patients and those isolated from the environment. However, isolates of identical type were frequently recovered from different patients within the same clinic and were found to be related in time and location. We conclude that the environment was not an important source of P. aeruginosa infection and that transfer of organisms was mainly from patient-to-patient.