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Objective To assess the optimal surgical approach and costs for patients hospitalized with septic bursitis. Patients and Methods From May 1, 2011, through December 24, 2014, hospitalized patients with septic bursitis at University of Geneva Hospitals were randomized (1:1) to receive 1- vs 2-stage bursectomy. All the patients received postsurgical oral antibiotic drug therapy for 7 days. Results Of 164 enrolled patients, 130 had bursitis of the elbow and 34 of the patella. The surgical approach used was 1-stage in 79 patients and 2-stage in 85. Overall, there were 22 treatment failures: 8 of 79 patients (10%) in the 1-stage arm and 14 of 85 (16%) in the 2-stage arm (Pearson χ 2 test; P =.23). Recurrent infection was caused by the same pathogen in 7 patients (4%) and by a different pathogen in 5 (3%). Outcomes were better in the 1- vs 2-stage arm for wound dehiscence for elbow bursitis (1 of 66 vs 9 of 64; Fisher exact test P =.03), median length of hospital stay (4.5 vs 6.0 days), nurses' workload (605 vs 1055 points), and total costs (Sw₣6881 vs Sw₣11,178; all P Conclusion For adults with moderate to severe septic bursitis requiring hospital admission, bursectomy with primary closure, together with antibiotic drug therapy for 7 days, was safe, effective, and resource saving. Using a 2-stage approach may be associated with a higher rate of wound dehiscence for olecranon bursitis than the 1-stage approach. Trial Registration Clinicaltrials.gov Identifier: NCT01406652.

To assess the optimal surgical approach and costs for patients hospitalized with septic bursitis.From May 1, 2011, through December 24, 2014, hospitalized patients with septic bursitis at University of Geneva Hospitals were randomized (1:1) to receive 1- vs 2-stage bursectomy. All the patients received postsurgical oral antibiotic drug therapy for 7 days.Of 164 enrolled patients, 130 had bursitis of the elbow and 34 of the patella. The surgical approach used was 1-stage in 79 patients and 2-stage in 85. Overall, there were 22 treatment failures: 8 of 79 patients (10%) in the 1-stage arm and 14 of 85 (16%) in the 2-stage arm (Pearson χFor adults with moderate to severe septic bursitis requiring hospital admission, bursectomy with primary closure, together with antibiotic drug therapy for 7 days, was safe, effective, and resource saving. Using a 2-stage approach may be associated with a higher rate of wound dehiscence for olecranon bursitis than the 1-stage approach.Clinicaltrials.gov Identifier: NCT01406652.

Problem: Need to decrease the number of requests for arterial blood gas analysis and increase their appropriateness to reduce the amount of blood drawn from patients, the time wasted by nurses, and the related cost. Design: Assessment of the impact of a multifaceted intervention aimed at changing requests for arterial blood gas analysis in a before and after study. Background and setting: Twenty bed surgical intensive care unit of a tertiary university affiliated hospital, receiving 1500 patients per year. Key measures for improvement: Number of tests per patient day, proportion of tests complying with current guideline, and safety indicators (mortality, incident rate, length of stay). Comparison of three 10 month periods corresponding to baseline, pilot (first version of the guideline), and consolidated (second version of the guideline) periods from March 1997 to August 1999. Strategies for change: Multifaceted intervention combining a new guideline developed by a multidisciplinary group, educational sessions, and monthly feedback about adherence to the guideline and use of blood gas analysis. Effects of change: Substantial decrease in the number of tests per patient day (from 8.2 to 4.8; P Lessons learnt: A multifaceted intervention can substantially decrease the number of requests for arterial blood gas analysis and increase their appropriateness without affecting patient safety.

P Garnerin, quality manager and F Clergue, department head and professor J-F Sicard, anaesthetist and F Bonnet, department head and professor Background—Reporting systems in anaesthesia have generally focused on critical events (including death) to trigger investigations of latent and active errors. The decrease in the rate of these critical events calls for a broader definition of significant anaesthetic events, such as hypotension and bradycardia, to monitor anaesthetic care. The association between merely undesirable events and critical events has not been established and needs to be investigated by voluntary reporting systems. Objectives—To establish whether undesirable anaesthetic events are correlated with critical events in anaesthetic voluntary reporting systems. Methods—As part of a quality improvement project, a systematic reporting system was implemented for monitoring 32 events during elective surgery in our hospital in 1996. The events were classified according to severity (critical/undesirable) and nature (process/outcome) and control charts and logistic regression were used to analyse the data. Results—During a period of 30 months 22% of the 6439 procedures were associated with anaesthetic events, 15% of which were critical and 31% process related. A strong association was found between critical outcome events and critical process events (OR 11.5 (95% confidence interval (CI) 4.4 to 27.8)), undesirable outcome events (OR 4.8 (95% CI 2.0 to 11.8)), and undesirable process events (OR 4.8 (95% CI 1.3 to 13.4)). For other classes of events, risk factors were related to the course of anaesthesia (duration, occurrence of other events) and included factors determined during the pre-anaesthetic visit (risk of haemorrhage, difficult intubation or allergic reaction). Conclusion—Undesirable events are associated with more severe events and with pre-anaesthetic risk factors. The way in which information on significant events can be used is discussed, including better use of preoperative information, reduction in the collection of redundant information, and more structured reporting. (Quality in Health Care 2000;9:203–209) Key Words: reporting system; correlation analysis; quality assessment; adverse events; anaesthesia

In health care organizations, management of both human and material resources implies decision making. When seemingly equivalent strategies are possible, simulation can help to make a decision on better grounds. The SHARE workframe was designed to address the specificities of health care and to provide a comprehensive environment for modelling and simulating health care processes. The typology of objects is defined as Actors, subdivided in Clients and Resources and Elementary Operations. Graphical tools allow us to build processes from these objects and to create their relationships. Various strategies based on either clinical or managerial changes may be investigated. After a simulation, graphical tools allow us to display summary information on the utilization of all actors, waiting times, and goodness of execution. The use of SHARE is exemplified with the analysis and simulation of changes in the Pulmonary Function Testing Laboratory of the Saint-Antoine Hospital, Paris.

A woman's risk of dying due to pregnancy or childbirth is approximately one in six in the poorest parts of the world and one in 30,000 in Northern Europe (Ronsmans & Graham, [2006]). In developed c...

To improve the computer connectivity and network strategies to connect U.S. county health departments (CHDs), state health departments (SHDs), and the Centers for Disease Control (CDC) for reporting notifiable conditions.HSPNET-L mailing list discussions and individual Internet communications were used to compare selected features of notifiable conditions networking in the United States, France, and the United Kingdom.In the US, the CHD is the agency that first responds to an infectious disease outbreak on receiving notifications from physicians. Prompt recognition by the SHD that a widespread outbreak has occurred depends on the way in which county data are received, the "age" of the data, and the time taken to analyze them. Similarly, the recognition of the national scale of the outbreak depends on the promptness with which SHDs report to the CDC and the age of the data. An analysis of the French Communicable Disease Network suggests that an expansion of electronic links between US CHDs and SHDs will improve timeliness. Electronic data exchange allows CHDs to set up a local database and reduces transcription errors, mailing costs, and telephone costs.A fuller use of e-mail or other electronic communication by US CHDs will allow them to use a local database as a tool for managing local disease outbreaks more effectively and independently. Federal and state agency access to the CHD databases will enable early reporting of epidemic outbreaks. Periodic posting of public health information on Internet servers is recommended for immediate access to the public health data by Internet users worldwide.

Summary Improving hospital operation in terms of quality of care, patient safety and efficiency requires the capacity to routinely analyse patient flow. To that end, a generic data model to represent patient trajectory across various hospital «compartments» (e.g. care units, clinical services, care levels) was developed. To build the model, time intervals during which a patient remains in the same set of compartments (e.g. the same care unit, the same clinical service, the same care level) were first identified for each stay using data extracted from the hospital information system. Each of these time intervals was then split into constant timesegments (i.e. days, hours) and the number of minutes the patient was present in each of them was counted. In addition, an entry flag (or exit flag) was attached to a timesegment if during this time-segment a patient entered (or left) a given compartment. The data model which was implemented on a MySQL-Infobright database using a starjoin schema allows, via basic SQL queries, a large array of analyses and detailed graphic visualisations of patient flow using numerous different time steps (month, weeks, days, weekdays, hours, etc.). By this means it dramatically increases the hospital’s capacity to address patient flow issues and prepare the way for patient flow simulation.

CONTEXT The immediate post-operative period is critical with regard to post-operative outcomes. OBJECTIVE To assess the impact of a clinical pathway implemented in a post-anaesthesia care unit on post-operative outcomes. DESIGN A retrospective cohort study based on electronic patient records. SETTING A post-anaesthesia care unit in a Swiss University Hospital. PATIENTS Adult patients after elective and non-elective surgery. INTERVENTION Implementation of a clinical pathway with a nurse-driven fast-track programme for uncomplicated patients (systematic use of Aldrete score and systematic discharge without physician) and a physician-driven slow-track programme for complicated patients (systematic handover between operating theatre and post-anaesthesia care unit, and between post-anaesthesia care unit and ward, systematic rounds, systematic use of standardised care for post-operative events, strict discharge criteria). MAIN OUTCOME MEASURES Post-anaesthesia care unit length of stay, in-hospital mortality and unplanned admission to the ICU after post-anaesthesia care unit stay. METHODS Comparison of the periods before and after implementation using median and interquartile range (IQR) and rates (%). STATISTICAL ANALYSIS unpaired Student's t-test, χ test, Wilcoxon rank test. Differences were adjusted through multivariate analyses with linear and logistic regression (level of significance: P

Data provided by the Sentinel General Practitioners (SGP) to the French Communicable Diseases Computer Network (FCDN) have been used to present the epidemiological characteristics of measles observed during a 6-year period in France. The estimated annual incidence rates per 100,000 population were 376 in 1985, 603 in 1986 and 983 in 1987, then declined during the following 3 years to 297, 258, and 263 per 100,000 population in 1988, 1989 and 1990 respectively. There is a marked seasonal change with a high early summer peak. The mean age among the cases for the 6 years of study varied from 5.4 to 6.0 years. There is an increase in the percentage of cases with a past history of measles vaccination, from 6.7% in 1985 to 12.8% in 1990. This increase may be interpreted as a consequence of a substantial increase of the vaccine coverage during the same period.

BACKGROUND AND OBJECTIVE: Distractions and interruptions during clinical activities can decrease performance and increase the risk of error. The incidence and impact of distracting events on anaesthetic teams during the critical phases of general anaesthesia are unknown. The purpose of this study was to quantify and analyse the frequency, the source and the impact of these events during the period of induction of general anaesthesia. METHODS: Twenty-nine anaesthetic team members participated in the study. Anaesthetic teams were videotaped during the induction period of a general anaesthesia. All videotapes were reviewed by two investigators using a scoring system in order to categorize the distracting events according to their origin, source, nature, duration, impact on patient and consequences on team activities. A total of 37 videotapes of general anaesthesia inductions for urgent surgical cases were analysed. RESULTS: The results show that the sources of distracting events are multiple and diverse. Distracting events occurred frequently (median five per video) and at least one event was present for 39.5% of the total observed period. They had a significant impact on the activity of the team members during 21.8% of the total observed period and had a negative impact on patient management in one-fifth of the cases. CONCLUSION: During the induction phase of general anaesthesia, distracting events are frequent and affect significantly the task at hand. Future research should design and implement preventive strategies to minimize the occurrence of unnecessary distracting events during this critical phase of anaesthesia when calm and vigilance should prevail.

OBJECTIVE: To assess the effect of a Crew Resource Management (CRM) intervention specifically designed to improve teamwork and communication skills in a multidisciplinary obstetrical setting. METHOD: Design--A before-and-after cross-sectional study designed to assess participants' satisfaction, learning and change in behaviour, according to Kirkpatrick's evaluation framework for training programmes. Setting--Labour and delivery units of a large university-affiliated hospital. Participants--Two hundred and thirty nine midwives, nurses, physicians and technicians from the department of anaesthesia, obstetrics and paediatrics. Intervention--All participants took part in a CRM-based training programme specifically designed to improve teamwork and communication skills. Principal measures of outcome-We assessed participants' satisfaction by means of a 10-item standardized questionnaire. A 36-item survey was administered before and after the course to assess participants' learning. Behavioural change was assessed by a 57-item safety attitude questionnaire measuring staff's change in attitude to safety over 1 year of programme implementation. RESULTS: Most participants valued the experience highly and 63-90% rated their level of satisfaction as being very high. Except for seven items, the 36-item survey testing participants' learning demonstrated a significant change (P

Background: The potential severity of wrong patient/procedure/site of surgery and the view that these events are avoidable, make the prevention of such errors a priority. An intervention was set up to develop a verification protocol for checking patient identity and the site of surgery with periodic audits to measure compliance while providing feedback. Assessment of problem: A nurse auditor performed the compliance audits in inpatients and outpatients during three consecutive 3-month periods and three 1-month follow-up periods; 11 audit criteria were recorded, as well as reasons for not performing a check. Strategy for change: The nurse auditor provided feedback to the health professionals, including discussion of inadequate checks. Results: 1000 interactions between patients and their anaesthetist or nurse anaesthetist were observed. Between the first and second audit periods compliance with all audit criteria except “surgical site marked” noticeably improved, such as the proportion of patients whose identities were checked (62.6% to 81.4%); full compliance with protocol in patient identity checks (9.7% to 38.1%); proportion of site of surgery checks carried out (77.1% to 92.6%); and full compliance with protocol in site of surgery checks (32.2% to 52.0%). Thereafter, compliance was stable for most criteria. The reason for failure to perform checks of patient identity or site of surgery was mostly that the anaesthetist in charge had seen the patient at the preanaesthetic consultation. Lessons and messages: By combining the implementation of a verification protocol with periodic audits with feedback, the intervention changed practice and increased compliance with patient identity and site of surgery checks. The impact of the intervention was limited by communication problems between patients and professionals, and lack of collaboration with surgical services.

Transfusion safety, time for a new partnership between stake-holders Following heightened publicity surrounding contaminated blood products, increased control has been implemented concerning all aspects of transfusion, from blood donor to finished product. A quality control programme has been implemented allowing a substantial reduction in adverse events. Transfusion medicine mandates the application of safety measures and hemo-vigilance helps to identify major risk factors in relation to bedside processes. Indeed, Swissmedic demands the application of such quality controls in every health institution. Given the enormous resources implicated with controlling transfusion products, isn't it time that National health authorities collaborate with local services in order to set a coherent transfusion policy and investment plan?

Quality improvement programs based on guidelines should change practice and reduce intraindividual and interindividual variations as well as variations between groups of caregivers. We analyzed a quality improvement program in 3 groups of caregivers. The groups modified differently their practice. Less experienced caregivers modified their practice the most, joining the more experienced professionals. This harmonization was achieved only during the last consolidation period. The analysis of practice could identify the quality of the implementation process and the group on which attention should be focused when such a quality improvement program is undertaken.

A regression model for the nonepidemic level of influenza-like syndrome has been estimated from the 55,200 cases collected between October 1984 and August 1988 using the French Communicable Diseases Computer Network. The start of a major epidemic in 1988-89 was detected early. The size of the epidemic, for the entire country, was estimated at approximately 4.3 million cases. The excess cost of sick-leave, among those of working age, was estimated at $86 million.

SITIE is a workstation devoted to epidemiological data selection, analysis, and representation. Epidemiological data are collected using the French Communicable Diseases computer Network and stored in an Oracle database. Disease selection and spatial and temporal representations can be done using a user friendly graphic interface. SITIE automatically generates SQL requests to the Oracle database, extracts the data, processes it according to the user's choice, and represents the data. SITIE is built upon the AVS graphic package and allows the creation of new applications using previously developed modules linked together to form a network. SITIE can be viewed as a tool box for epidemiological data representations. Three example applications are detailed in order to make clear the way a new application can be built using SITIE. The reusability of modules is exemplified by a compound application.

This paper describes an information system (IS) established in France in 1984 for the national surveillance of communicable diseases. This IS is based on a videotex server and a relational database management system. The videotex server is the IS front-end. It performs the following functions: interpersonal communications, synthetic information retrieval into an epidemiologic info-base and data entry owing to its specialized applications. The relational database management system allows the user to manage and consult an epidemiologic database updated in quasi-real time. Several specific tools have also been developed in order to enhance data representation and analysis and the decision support capabilities of the IS.

The temporal and spatial association of meningococcal disease and influenza-like syndrome (ILS) was assessed from surveillance data on these diseases in France for a 6-year period (1985-1990). Using time series methods to account for the usual seasonal pattern meningococcal disease, the incidence of meningococcal disease in a given week was found to be linked to incidence of ILS in the 5 previous weeks but not to that in subsequent weeks. Geographic spread of meningococcal disease correlated with spread of ILS. This study also suggests that meningococcal disease is more severe for a 2-month period during and after an ILS epidemic: The proportion of cases with purpura fulminans increased by 24% and those resulting in death by 26% during this period. No shift in the age distribution was observed. When an ILS epidemic is identified, medical practitioners should be informed of the likelihood of an increased incidence and severity of meningococcal disease.