One- vs 2-Stage Bursectomy for Septic Olecranon and Prepatellar Bursitis: A Prospective Randomized Trial.

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 χ2 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<.01). 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.

A clinical pathway in a post-anaesthesia care unit to reduce length of stay, mortality and unplanned intensive care unit admission.

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 < 0.05) and expressed as odds ratio (OR) with 95% confidence interval (95% CI). RESULTS: After implementation, the median post-anaesthesia care unit length of stay decreased for all patients from 163 min (IQR 103-291) to 148 min (IQR 96-270; P < 0.001); in the American Society of Anaesthesiologists 1-2 patients, it decreased from 152 min (IQR 102-249) to 135 min (IQR 91-227; P < 0.001). In-hospital mortality decreased for all patients from 1.7 to 0.9% [adjusted OR 0.36 (95% CI 0.22-0.59), P < 0.001]. The number of unplanned admissions to the ICU decreased from 113 (2.8%) to 91 (2.1%) [adjusted OR 0.73 (95% CI 0.53-0.99), P = 0.04]. CONCLUSION: A clinical pathway in a post-anaesthesia care unit can significantly reduce length of stay and can improve post-operative outcome.

Incidence and impact of distracting events during induction of general anaesthesia for urgent surgical cases.

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.

Effect of crew resource management training in a multidisciplinary obstetrical setting.

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<0.05) towards better knowledge of teamwork and shared decision making after the training programme. Over the year of observation, there was a positive change in the team and safety climate in the hospital [odds ratio (OR) 2.9, 95% confidence interval (CI) (1.3-6.3) to OR 4.7, 95% CI (1.2-17.2)]. **There was also improved stress recognition [OR 2.4, 95% CI (1.2-4.8) to OR 3.0, 95% CI (1.0-8.8)]. CONCLUSION: The implementation of a training programme based on CRM in a multidisciplinary obstetrical setting is well accepted and contributes to a significant improvement in interprofessional teamwork.

Point of care management of heparin administration after heart surgery: A randomized, controlled trial.

OBJECTIVES: Determination of activated partial thromboplastin time (aPTT) is used in coagulation management after heart surgery. Results from the central laboratory take long to be obtained. We sought to shorten the time to obtain coagulation results and the desired coagulation state and to reduce blood loss and transfusions using point of care (POC) aPTT determination. DESIGN: Randomized, controlled trial. SETTING: University-affiliated 20-bed surgical ICU. PATIENTS AND PARTICIPANTS: Forty-two patients planned for valve surgery (Valves) and 84 for coronary artery bypass grafting (CABG) with cardiopulmonary bypass. INTERVENTIONS: Valves and CABG were randomized to postoperative coagulation management monitored either by central laboratory aPTT (Lab group) or by POC aPTT (POC group). Heparin was administered according to guidelines. MEASUREMENTS AND RESULTS: POC aPTT results were available earlier than Lab aPTT after venipuncture in Valves (3 +/- 2 vs. 125 +/- 68 min) and in CABG (3 +/- 4 vs. 114 +/- 62 min). Heparin was introduced earlier in the POC group in Valves (7 +/- 23 vs. 13 +/- 78 h, p = 0.01). Valves of the POC group bled significantly less than Valves in the Lab group (647 +/- 362 ml vs. 992 +/- 647 ml, p < 0.04), especially during the first 8 h after ICU admission. There was no difference in bleeding in CABG (1074 +/- 869 ml vs. 1102 +/- 620, p = NS). In Valves, fewer patients in the POC group than in the Lab group needed blood transfusions (1/21 vs. 8/21; p = 0.03). No difference was detected in CABG. CONCLUSIONS: In Valves in the POC group the time to the desired coagulation state was reduced, as was the thoracic blood loss, reducing the number of patients transfused. This improvement was not observed in CABG. Side effects were similar in the two groups.

[Transfusion safety, time for a new partnership between stake-holders]. / Sécurité transfusionnelle ou le temps venu de la concertation.

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?

Harmonization of practice among different groups of caregivers: a guideline on arterial blood gas utilization.

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.