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ObjectiveHealthcare workers are at high risk of experiencing stress and fatigue due to the demands of their work within hospitals. Improving their physical and mental health and in turn, the quality and safety of care, requires considering factors at both individual and organizational levels. Using a multi-center prospective cohort, this study aims to identify the individual and organizational predictors of stress and fatigue of healthcare workers in several wards from university hospitals.MethodsOur cohort consist of 695 healthcare workers from 32 hospital wards drawn at random within four volunteer hospital centers in Paris-area. Three-level longitudinal analyses, accounting for repeated measures (level 1) across participants (level 2) nested within wards (level 3) and adjusted for relevant fixed and time varying confounders were performed.ResultsAt baseline, the sample was composed by 384 registered nurses, 300 auxiliary nurses and 11 midwives. According to the 3-level longitudinal models, some predictors were found in common for both stress and fatigue (low support from the hierarchy, low safety culture, overcommitment at work, presenteeism while sick…). However, specific predictors for high level of stress (negative life events, low support from the colleagues and high frequency of break cancellation) and fatigue (commuting duration, frequent use of interim staff in the ward…) were also found.ConclusionOur results may help identify at-risk healthcare workers and wards, where interventions to reduce stress and fatigue should be focused. These interventions could include manager training to favor better staff support and overall safety culture of healthcare workers.1.What is already known about this subject?Healthcare workers have high levels of perceived stress and fatigue, particularly in medical fields highly exposed to infectious risks.High occupational stress and fatigue can negatively affect healthcare workers behaviors in terms of absenteeism, and ultimately intention to leave as well as quality of care.Individual and organizational differences contribute to different perceptions and consequences of occupational stress and fatigue in healthcare workers.2.What are the new findings?The ward-level environment significantly influences the stress and fatigue of healthcare workers, in addition to individual factors and time variations.Hierarchy providing low support and with low safety culture, work overinvestment, presenteeism while sick, and working in smaller wards were identified as predictors of both high stress and fatigue of healthcare workers.Negative life events (whether personal or professional), low support from the colleagues and high frequency of break cancellation are specific predictors of high level of stress. While commuting duration, frequent use of interim staff and working in a medical ward were associated with high level of fatigue.3.How might this impact on policy or clinical practice in the foreseeable future?In this study, we can identify some areas for improvement to better prevent stress and fatigue for healthcare workers. High stress and fatigue can be reduced through mutual and specific organizational intervention strategies.

ObjectiveHealthcare workers (HCWs) are at high risk of experiencing stress and fatigue due to the demands of their work within hospitals. Improving their physical and mental health and, in turn, the quality and safety of care requires considering factors at both individual and organisational/ward levels. Using a multicentre prospective cohort, this study aims to identify the individual and organisational predictors of stress and fatigue of HCWs in several wards from university hospitals.MethodsOur cohort consists of 695 HCWs from 32 hospital wards drawn at random within four volunteer hospital centres in Paris-area. Three-level longitudinal analyses, accounting for repeated measures (level 1) across participants (level 2) nested within wards (level 3) and adjusted for relevant fixed and time-varying confounders, were performed.ResultsAt baseline, the sample was composed by 384 registered nurses, 300 auxiliary nurses and 11 midwives. According to the three-level longitudinal models, some predictors were found in common for both stress and fatigue (low social support from supervisors, work overcommitment, sickness presenteeism and number of beds per ward). However, specific predictors for high level of stress (negative life events, low social support from colleagues and breaks frequently cancelled due to work overload) and fatigue (longer commuting duration, frequent use of interim staff in the ward) were also found.ConclusionOur results may help identify at-risk HCWs and wards, where interventions to reduce stress and fatigue should be focused. These interventions could include manager training to favour better staff support and overall safety culture of HCWs.

Objective:The French National Authority for Health (HAS), with a multidisciplinary working group, developed an indicator ‘ISO-ORTHO’ to assess surgical site infections (SSIs) after total hip arthroplasty or total knee arthroplasty (THA/TKA) based on the hospital discharge database. We present the ISO-ORTHO indicator designed for SSI automated detection and its relevance for quality improvement and hospital benchmarks.Methods:The algorithm is based on a combination of International Statistical Classification of Diseases, Tenth Revision (ICD-10) and procedure codes of the hospital stay. The target population was selected among adult patients who had a THA or TKA between January 1, 2017, and September 30, 2017. Patients at very high risk of SSI and/or with SSI not related to hospital care were excluded. We searched databases for SSIs up to 3 months after THA/TKA. The standardized infection ratio (SIR) of observed versus expected SSIs was calculated (logistic regression) and displayed as funnel plot with 2 and 3 standard deviations (SD) after adjustment for 13 factors known to increase SSI risk.Results:In total, 790 hospitals and 139,926 THA/TKA stays were assessed; 1,253 SSI were detected in the 473 included hospitals (incidence, 0.9%: 1.0% for THA, 0.80% for TKA). The SSI rate was significantly higher in males (1.2%), in patients with previous osteo-articular infection (4.4%), and those with cancer (2.3%), obesity, or diabetes. Most hospitals (89.9%) were within 2 SD; however, 12 hospitals were classified as outliers at more than +3 SD (1.6% of facilities), and 59 hospitals (7.9%) were outliers between +2 SD and +3 SD.Conclusion:ISO-ORTHO is a relevant indicator for automated surveillance; it can provide hospitals a metric for SSI assessment that may contribute to improving patient outcomes.

Introduction. L’endophtalmie est une complication rare et grave de la chirurgie de la cataracte qui peut entraîner une perte définitive de l’œil. Les estimations du risque en France restent incomplètes car les systèmes de surveillance existants sont peu adaptés en chirurgie ambulatoire. L’objectif de ce travail a été de déterminer l’incidence et les facteurs de risque des endophtalmies après chirurgie de la cataracte (ECC). Méthode. La cohorte des individus opérés pour cataracte entre 2009 et 2014, extraite de la base du programme médicalisé des systèmes d’information, constitue l’échantillon étudié. Toutes les ECC dans l’année suivant la chirurgie ont été sélectionnées selon la classification internationale des maladies CIM-10. Une analyse par régression de Poisson a été effectuée pour l’analyse des facteurs de risque à partir des comorbidités associées. Résultats. Au total 4 200 733 interventions de la cataracte ont été effectuées sur la période d’étude. L’incidence des ECC (5/10 000) a diminué de 61 % entre 2009 et 2014. Dans l’analyse multivariée, le cancer, l’hypertension artérielle, la déchirure capsulaire, l’âge (< 55 ans) et le sexe masculin ont été associés à un risque accru d’ECC. À l’inverse, l’injection intracamérulaire de céfuroxime en prophylaxie a été associée à un risque plus faible d’ECC. Conclusion. Une diminution significative de l’incidence des ECC a été observée sur la période d’étude. Le rôle de l’antibioprophylaxie dans cette évolution mérite cependant d’être clarifié.

International audience

The aim of this study was to determine which surgical antibiotic prophylaxis (SAP) practices alter surgical site infection (SSI) risk.Data were collected during a 7 year surveillance period (2001-07) from volunteer surgery wards participating in the INCISO Surveillance Network in Northern France. Main SAP practices, i.e. antibiotic choice, timing of first dose and total SAP duration, were evaluated and compliance checked based on French recommendations. The study focused on selected procedures in digestive, orthopaedic, gynaecological and cardiovascular surgery, for which standard SAP is recommended. Multilevel logistic regression analysis (a two-level random effect model) was carried out to identify SAP-, patient- and procedure-specific factors associated with SSI.Of 8029 patients who underwent the selected surgeries, 91.3% received SAP and 2.5% developed SSI. Among those receiving SAP, 83.3% received appropriate antibiotic agents and 76.6% had an optimal timing of administration. SAP duration was considered to be appropriate in 35.0%, too long (SAP unnecessarily prolonged) in 45.2% and too short (lack of intra-operative redosing when recommended) in 19.8%. In the multivariate analysis, a too-short SAP duration remained the only inappropriate practice associated with higher SSI risk (odds ratio = 1.8, 95% confidence interval: 1.14-2.81), after adjustment for surgery procedure group, the National Nosocomial Infections Surveillance System risk index, age and infection risk variability among hospitals. No significant relationships were observed between SSI and the other SAP parameters.A too-short SAP duration was the most important SAP malpractice associated with an increased risk of SSI. Information directed at practitioners should be reinforced based on standard recommendations.

In France, antibiotic consumption (ABC) is dramatically high in parallel with the high rate of multidrug-resistant bacteria. For the last few years, a nationwide policy has been implemented at the national level to control and monitor ABC. Since 2002, surveillance networks have been set up with voluntary hospitals to evaluate the antibiotic policy and consumption. The present study was conducted to identify whether specific control measures of the antibiotic policy could reduce ABC in hospitals.Based on the data from the Northern France surveillance system, local recommendations and antibiotic use were collected annually on a standardized questionnaire that had 21 items. ABC was expressed in defined daily doses (DDDs) per 1000 patient-days (PDs). The ABC indicator was the overall antibiotic consumption. A multivariate logistic regression analysis was performed using low (or =75th percentile) and high (75th percentile) ABC as the dependent variable.A total of 83/111 hospitals were included in the study. In 75% of the hospitals, total ABC wasor =669.5 DDDs/1000 PDs. The less frequent practices were educational antibiotic programmes (17%), authorization from an antibiotic specialist for selected antibiotics (26%) and systematic reassessment of AB treatment after 72 h (27%). In the multivariate analysis, three variables remained significantly and independently associated (P0.05) with ABC: the type of hospital, the proportion of non-acute-care beds and the nominative delivery form as the only antibiotic control measure. Total ABC was lower in hospitals having a nominative delivery form, compared with hospitals not having it. Conversely, ABC was significantly higher in public teaching hospitals compared with non-teaching hospitals. Similarly, ABC was higher in hospitals with a lowest proportion (i.e.or =25%) of non-acute-care beds compared with hospitals where this proportion was25%.Specific control measures could lower ABC. Sustained control efforts should focus on antibiotics with the highest potential for emerging bacterial resistance.

Studies provide evidence that reduced nurse staffing resources are associated to an increase in health care-associated infections in intensive care units, but tools to assess the contribution of the mechanisms driving these relations are still lacking. We present an agent-based model of pathogen spread that can be used to evaluate the impact on nosocomial risk of alternative management decisions adopted to deal with transitory nurse shortage., We constructed a model simulating contact-mediated dissemination of pathogens in an intensive-care unit with explicit staffing where nurse availability could be temporarily reduced while maintaining requisites of patient care. We used the model to explore the impact of alternative management decisions adopted to deal with transitory nurse shortage under different pathogen- and institution-specific scenarios. Three alternative strategies could be adopted: increasing the workload of working nurses, hiring substitute nurses, or transferring patients to other intensive-care units. The impact of these decisions on pathogen spread was examined while varying pathogen transmissibility and severity of nurse shortage., The model-predicted changes in pathogen prevalence among patients were impacted by management decisions. Simulations showed that increasing nurse workload led to an increase in pathogen spread and that patient transfer could reduce prevalence of pathogens among patients in the intensive-care unit. The outcome of nurse substitution depended on the assumed skills of substitute nurses. Differences between predicted outcomes of each strategy became more evident with increasing transmissibility of the pathogen and with higher rates of nurse shortage., Agent-based models with explicit staff management such as the model presented may prove useful to design staff management policies that mitigate the risk of healthcare-associated infections under episodes of increased nurse shortage.