ABSTRACT
BACKGROUND: New scheduling models were needed to adjust to residents' duty hour reforms while maintaining safe patient care. In interdisciplinary night-float rotations, four to six residents from most residency programs collaborated for after-hours cross-coverage of most adult hospitalised patients as part of a Faculty-led rotation. Residents worked sixteen 12-hour night shifts over a month. METHODS: We measured residents' perception of the patient safety climate during implementation of night-float rotations in five tertiary hospitals. We surveyed 267 residents who had completed the rotation in 2015-2016 with an online version of the Safety Attitudes Questionnaire. First year residents came from most residency programs, second- and third-year residents came from internal medicine. RESULTS: One-hundred-and-thirty residents completed the questionnaire. Scores did not differ across hospitals and residents' years of training for all six safety-related climate factors: teamwork climate, job satisfaction, perceptions of management, safety climate, working conditions, and stress recognition. CONCLUSION: Simultaneous implementation in five hospitals of a Faculty-led interdisciplinary night-float rotation for most junior residents proved to be logistically feasible and showed similar and reassuring patient safety climate scores.
CONTEXTE: De nouveaux horaires de garde en établissements hospitaliers étaient nécessaires pour s'adapter aux réformes des heures de travail des résidents tout en maintenant des soins sécuritaires pour les patients. Dans les stages cliniques de nuit interdisciplinaires, quatre à six résidents de la plupart des programmes de résidence ont collaboré pour assurer une couverture croisée, après les heures normales de travail, de la plupart des patients adultes hospitalisés. Les résidents ont travaillé seize nuits de 12 heures durant un mois. MÉTHODES: Nous avons mesuré la perception des résidents du climat de travail lié à la sécurité des patients lors de la mise en place de stages de nuit dans cinq hôpitaux universitaires. Nous avons interrogé 267 résidents ayant terminé le stage en 2015-2016 avec une version numérique du Safety Attitudes Questionnaire. Les résidents de première année provenaient de la plupart des programmes de résidence, les résidents de deuxième et troisième années provenaient du programme de médecine interne. RÉSULTATS: 130 résidents ont complété le questionnaire. Les scores ne différaient pas entre les hôpitaux et les années de formation des résidents pour les six facteurs liés à la sécurité des patients: climat de travail en équipe, satisfaction au travail, perceptions des supérieurs, climat de sécurité, conditions de travail et reconnaissance du stress. CONCLUSIONS: La mise en place simultanée, dans cinq hôpitaux, de stages cliniques de nuit réunissant des résidents juniors de la majorité des programmes de résidence fut logistiquement possible et a montré des résultats similaires et rassurants sur le climat de travail lié à la sécurité des patients.
ABSTRACT
Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin is used for the prevention of cardiovascular events following percutaneous coronary intervention (PCI). These agents increase the risk of gastrointestinal bleeding. To prevent these events, proton pump inhibitors (PPI) are routinely prescribed. It has been reported that with the exception of pantoprazole and dexlanzoprazole, PPIs can impede conversion of clopidogrel by cytochrome P450 2C19 (CYP2C19) to its active metabolite, a critical step required for clopidogrel efficacy. Changes in CYP2C19 enzyme activity (phenotype) and its correlation with platelet reactivity following PPI therapy has not yet been fully described. In this study we attempted to determine if the [ (13)C]-pantoprazole breath test (Ptz-BT) can evaluate changes in CYP2C19 enzyme activity (phenoconversion) following the administration of PPI in coronary artery disease (CAD) patients treated with DAPT after PCI. Thirty (30) days after successful PCI with stent placement, 59 patients enrolled in the Evaluation of the Influence of Statins and Proton Pump Inhibitors on Clopidogrel Antiplatelet Effects (SPICE) trial (ClinicalTrials.gov Identifier: NCT00930670) were recruited to participate in this sub study. Patients were randomized to one of 4 antacid therapies (omeprazole, esomeprazole. pantoprazole or ranitidine). Subjects were administered the Ptz-BT and platelet function was evaluated by vasodilator-stimulated phosphoprotein (VASP) phosphorylation and light transmittance aggregometry before and 30 d after treatment with antacid therapy. Patients randomized to esomeprazole and omeprazole had greater high on-treatment platelet reactivity and lowering of CYP2C19 enzyme activity at Day 60 after 30 d of PPI therapy. Patients randomized to ranitidine and pantoprazole did not show any changes in platelet activity or CYP 2C19 enzyme activity. In patients treated with esomeprazole and omeprazole, changes in CYP2C19 enzyme activity (phenoconversion) correlated well with changes in platelet reactivity. Co-administration of omeprazole or esomeprazole in patients treated with clopidogrel results in lower CYP2C19 enzyme activity and increased platelet reactivity as measured by VASP phosphorylation test while patients given pantoprazole or ranitidine did not show any significant changes in CYP2C19 enzyme activity and platelet reactivity.
