Successful implementation of guidelines for encouraging the use of beta blockers in patients after acute myocardial infarction.

PURPOSE: To assess whether implementation of guidelines increases the prescription of drugs, particularly beta blockers, recommended for secondary prevention after acute myocardial infarction. SUBJECTS AND METHODS: Prescription patterns among 355 patients discharged from a public teaching hospital after recovery from myocardial infarction were prospectively monitored in a before-after trial. The implementation strategies included educational interventions (large group meetings), placement of guidelines in patients' records, and bimonthly general reminders sent to physicians. RESULTS: Beta blockers were prescribed in 93 (38%) of 243 survivors of acute myocardial infarction before guideline implementation (12-month control period), as compared with 71 (63%) of 112 patients (P <0.001) after their implementation (6-month period). During the entire study period, the prescription of beta blockers at a neighboring public teaching hospital, used as a comparison, was unchanged. After adjusting for potential confounders, implementation of the guidelines remained significantly associated with prescription of beta blockers at discharge [odds ratio (OR) = 10; 95% confidence interval (CI), 3.2 to 33; P <0.001]. Other independent predictors of prescription of beta blockers were previous coronary artery bypass grafting (OR = 8.7; 95% CI, 2.5 to 31; P = 0.001), hypertension (OR = 2.5; 95% CI, 1.4 to 4.5; P = 0.003), age per 10-year increase (OR = 0.82; 95% CI, 0.67 to 0.99; P = 0.04), secular trend in prescription patterns expressed in months (OR = 0.9; 95% CI, 0.8 to 1.0; P = 0.02), a left ventricular ejection fraction < or = 40% (OR = 0.2; 95% CI, 0.1 to 0.4; P <0.001), the presence of atrioventricular block (OR = 0.1; 95% CI, 0.02 to 0.7; P = 0.02), and concomitant prescription of digoxin (OR = 0.2; 95% CI, 0.05 to 0.8; P = 0.02) or calcium antagonists (OR = 0.06; 95% CI, 0.01 to 0.3; P = 0.001). CONCLUSION: When appropriately developed and implemented by local experts, literature-based guidelines may be effective in modifying use of recommended drugs for secondary prevention of coronary artery disease, such as prescription of beta blockers.

Hospital-acquired pressure ulcers: risk factors and use of preventive devices.

BACKGROUND: Pressure ulcers are a frequent complication of bed rest. We examined risk factors for hospital-acquired pressure ulcers, the use of preventive devices, and the impact of case-mix adjustments on between-ward comparisons. METHODS: We conducted 3 cross-sectional surveys in a teaching hospital of 2373 patients who had no pressure ulcer on admission. We assessed the presence of pressure ulcer, dates of admission and ulcer occurrence, hospital ward, patient age and sex, appetite and route of nutrition, surgery during stay, hospitalization for fracture, comorbidities, use of low-pressure devices (special mattresses, cushions, and pressure-reducing beds), and the Norton Pressure Ulcer Prediction score (physical condition, mental condition, activity, mobility, and incontinence). RESULTS: Two hundred forty-seven new pressure ulcers occurred (5.7 per 1000 person-days). In multivariate analysis, the risk for pressure ulcer increased with age (risk gradient across 5 categories was 1:4.5; P<.001) and Norton score (across 5 categories, risk gradient was 30-fold; P<.001); other risk factors (all relative risks, 1.5-1.8; P<.002) were hospitalization for fracture, surgical intervention, reduced appetite, and nasogastric tube or intravenous nutrition. Adjustment for case mix substantially modified differences between hospital wards. Use of preventive devices was associated with Norton score, but not all high-risk patients benefited. CONCLUSIONS: Pressure ulcers were seen in every 10th hospitalized adult. Patient age and Norton score were the strongest risk factors for pressure ulcers. Use of preventive devices was suboptimal. Adjustment for case mix is essential if pressure ulcer incidence is to be used as an indicator of quality of care.

Contribution of individual items to the performance of the Norton pressure ulcer prediction scale.

OBJECTIVES: To assess the specific contribution to overall scale performance of each of the five items that constitute the Norton pressure ulcer prediction scale. DESIGN: A comparison of statistical models based on cross-sectional surveys of hospitalized patients. SETTING: An urban teaching hospital in Geneva, Switzerland. PARTICIPANTS: 2373 hospitalized patients who were free of pressure ulcers on admission. MEASUREMENTS: Norton scale items measuring activity, mobility, physical condition, mental condition, and incontinence on a 4-point scale were examined as predictors of stage 1 or greater pressure ulcers. RESULTS: A total of 245 new pressure ulcers occurred between admission and patient observation. After adjustment for other independent predictors in proportional hazards models, only the activity and mobility items remained associated significantly with the risk of pressure ulcer. A simplified 2-item scale was more strongly associated with pressure ulcer risk than was the classic 5-item Norton scale. CONCLUSIONS: Our study suggests that the activity and mobility items of the Norton scale are sufficient to express the risk of pressure ulcers in hospitalized patients. Confirmation of this finding in prospective studies is warranted.

Do physicians modify their prehospital management of patients in response to a public campaign on chest pain?

The goals of this study were to analyze the impact of a public campaign on chest pain on physicians involved in the prehospital care of patients with this symptom, in terms of physician delay, rates of immediate hospitalization, and of transportation by ambulance. Prehospital delays and decisions for all 866 patients with chest pain managed by the community and generalist physicians or by emergency physicians, who presented to the emergency department of a teaching hospital during the 12 months of the campaign, were compared with those of all 749 patients with similar presentations during the 12 months before it. When community and generalist physicians were involved, median (110 minutes) physician delay did not decrease during the campaign, whereas it decreased from 65 to 56 minutes (p <0.003) when emergency physicians were involved. Rates of immediate hospitalization (73%) and of transportation by ambulance (47%) of patients managed by community and generalist physicians were unaffected by the campaign, whereas they increased from 96% and 89%, respectively, to 98% (p = 0.09) and 94% (p <0.02) when emergency physicians were involved. Similar observations were made in patients with confirmed acute myocardial infarction and unstable angina and remained highly significant after adjustment for differences in clinical characteristics. Thus, community and generalist physicians did not significantly modify their prehospital management of patients with chest pain despite a public campaign. To be successful, guidelines on the matter have to be developed with the active participation of these physicians.

Impact of a public campaign on pre-hospital delay in patients reporting chest pain.

OBJECTIVE: To decrease pre-hospital delay in patients with chest pain. DESIGN: Population based, prospective observational study. SETTING: A province of Switzerland with 380000 inhabitants. SUBJECTS: All 1337 patients who presented with chest pain to the emergency department of the Hôpital Cantonal Universitaire of Geneva during the 12 months of a multimedia public campaign, and the 1140 patients who came with similar symptoms during the 12 months before the campaign started. MAIN OUTCOME MEASURES: Pre-hospital time delay and number of patients admitted to the hospital for acute myocardial infarction (AMI) and unstable angina. RESULTS: Mean pre-hospital delay decreased from 7h 50 min before the campaign to 4 h 54 min during it, and median delay from 180 min to 155 min (P < 0.001). For patients with a final diagnosis of AMI, mean delay decreased from 9 h 10 min to 5 h 10 min and median delay from 195 min to 155 min (P < 0.002). Emergency department visits per week for AMI and unstable angina increased from 11.2 before the campaign to 13.2 during it (P < 0.02), with an increase to 27 (P < 0.01) during the first week of the campaign; visits per week for non-cardiac chest pain increased from 7.6 to 8.1 (P = NS) during the campaign, with an increase to 17 (P < 0.05) during its first week. CONCLUSIONS: Public campaigns may significantly reduce pre-hospital delay in patients with chest pain. Despite transient increases in emergency department visits for non-cardiac chest pain, such campaigns may significantly increase hospital visits for AMI and unstable angina and thus be cost effective.

[Delay in management and treatment of patients with suspected acute myocardial infarction: role of the public, of extra- and intra-hospital structures and transportation methods]. / Délais dans la prise en charge et le traitement des patients avec suspicion d'infarctus aigu du myocarde: le rôle du public, des structures extra- et intra-hospitalières et des moyens de transports.

The potential impact of thrombolytic agents on mortality and morbidity from coronary artery disease is weakened by in- and out-of-hospital delays occurring in the management of acute myocardial infarction. The goals of this study were to review the situation 5 years after the publication of the GISSI study. From October 1, 1991 to March 31, 1992, all the events occurring between symptom onset and in-hospital treatment were analyzed for 620 consecutive patients with suspected myocardial infarction seen in the emergency ward of the University Hospital, Geneva. Among them, 189 (30.5%) had myocardial infarction and 144 (23%) unstable angina. Mean and median delay between symptom onset and hospital arrival for the 620 patients were 10 h 02 min and 2 h 55 min respectively; 117 (19%) patients came straight to the hospital alone, with the risk of arrhythmic complications en route to the emergency ward but with shorter time delays (mean delay: 6 h 13 min; median delay: 2 h 30 min) than the 503 (81%) patients who called out-of-hospital services (mean delay: 10 h 55 min; median delay: 3 h; p < 0.04). The latter patients accounted for 47% of mean out-of-hospital delay and the out-of-hospital services for 53%. Minimization or ignorance of symptoms, waiting for relief from medication and attempts to reach relatives were responsible for long patients' decision times.(ABSTRACT TRUNCATED AT 250 WORDS)