Quality assessment in surgical care departments: proposal for a scoring system in terms of structure and process.

OBJECTIVE: To build a score able to reflect and rank surgical departments according to a definition of "quality" in terms of structure and process. METHODS: Collaborative design of a quality score in the framework of the French clinical research project NosoQual. Feasibility and observational study in 46 surgical departments visited between November 2002 and March 2003 according to standardised procedures. A bibliographic review followed by expert consultations, a field test, analysis and a final reconsideration leading to the definition of a consensual score. RESULTS: 138 variables comprised the score. They were classified into seven dimensions, each representing a different aspect of quality of care in surgery. According to the threshold and weight attributed to every variable, scores were calculated for each department. The average level of achievement of the scores varied from 42% to 71% of theoretical maxima. The variability of the scores related to the seven dimensions was larger and more significant than the one expressed by the overall score (coefficient of variation=0.1). CONCLUSION: This analytical work contributed to the design of a quality score for surgery. However, the progress of the score should continue to take into account all the obstacles that were observed and to meet the high requirements of the actual patient safety issue.

[Coordination of health vigilances: for a global management of hospital risks]. / La coordination des vigilances sanitaires : pour une gestion plus globale des risques hospitaliers.

The sanitary vigilances represent a permanent sanitary surveillance. They signal, enregister, treat and investigate the adverse events occurring through the use of health products. They assure the traceability of these health products and the management of the sanitary alerts. The sanitary vigilances are part of the sanitary security. They are optimized when coordinated and integrated to the global risk management process of the health care establishments.

[Antimicrobial prophylaxis in surgical procedures: assessment of the guidelines application and validation of antibiotic prophylaxis kits]. / Antibioprophylaxie chirurgicale: évaluation de l'application des recommandations et validation des kits d'antibioprophylaxie.

INTRODUCTION: Surgical wounds infections represent a major cause of morbidity and are at the origin of an increase in the postoperative mortality rate. Those infections represent in France one-fourth of the nosocomial infections. Combine with the elementary hygiene rules and the surgical "good practices", antimicrobial prophylaxis with antibiotics is an essential tool for the reduction of the surgical wound infections rate. In the French hospitals, antimicrobial prophylaxis represents one-third of the antibiotic prescriptions. The rules for the application of surgical prophylaxis are based on current guidelines for antibiotic prophylaxis, however, guidelines are not totally respected. MATERIALS AND METHODS: Study 1: assessment of the guidelines application (practical audit) of the antibiotic antimicrobial prophylaxis in surgery, and of their impact on the established prescriptions: three audits were realized with four years interval (1994, 1998 and 2002), in order to estimate the evolution in the application of the current guidelines, which indirectly estimate the evolution of the guidelines impact. Study 2: assessment of the use of an antibiotic kit through a prospective comparative study of two groups: exposed patients vs non-exposed patients. Nominatives kits contained the recommended antibiotics with recommended posology and the instructions for each surgical procedure. RESULTS: Study 1: this study showed a significant increase in the antibiotics prescription volume since 1994 (+23%). After a temporary increase from 1994 to 1998, the conformity of the effective prescriptions with the current guidelines for the indication to realize or not to realize an antibiotic surgical prophylaxis decreases of 7% between 1998 and 2002. Nevertheless, we noticed an overall improvement in the guidelines application for the modalities of the antimicrobial prophylaxis when it was prescribed in a valid indication. Persistent weak points were in 2002 the antibiotic molecule choice (error rate of 25%), the duration of prescription (rate of abnormal prolonged antibiotic prophylaxis of 19%), and the timing of administration (error rate of 31%). Study 2: antibiotic kits have permitted to increase the accordance of the antimicrobial prophylaxis prescriptions with the guidelines. Antibiotic prophylaxis was in total agreement with guidelines for 82% of exposed patients vs 41 for non-exposed patients. Choice of the antibiotic molecule, timing of administration and duration of prescription were the parameters particularly well rectified by this new antibiotic prophylaxis technical. CONCLUSION: In this study, guidelines diffusion seems to be an essential but also an insufficient point for the improvement of the quality prescriptions in surgical antimicrobial prophylaxis. The "day by day" nominative antibiotic prophylaxis deliverance in the shape of a << ready to use >> antibiotic kit went with an increase in the respect of the recommendations, by correcting in a significant way the persistent weak points identified during the first part of our study. The antibiotic prescriptions control is an imperative goal in individual health (the patient himself), but also in public health (the community). This radical change in habits is listed in a policy of antimicrobial agent prescription improvement (best efficacy with less cost).

[How the information system can contribute to the implementation of a risk management program in a hospital?]. / Comment le système d'information peut-il aider un programme de gestion des risques en établissement de santé?

Nowadays, information system is recognised as one of the key points of the management strategy. An information system is regarded conceptualised as a mean to link 3 aspects of a firm (structure, organisation rules and staff). Its design and implementation have to meet the objectives of medical and economical evaluation, especially risk management objectives. In order to identify, analyse, reduce and prevent the occurrence of adverse events, and also to measure the efficacy and efficiency of the production of care services, the design of information systems should be based on a process analysis in order to describe and classify all the working practices within the hospital. According to various methodologies (usually top-down analysis), each process can be divided into activities. Each activity (especially each care activity) can be described according to its potential risks and expected results. For care professionals performing a task, the access to official or internal guidelines and the adverse events reporting forms has also to be defined. Putting together all the elements of such a process analysis will contribute to integrate, into daily practice, the management of risks, supported by the information system.

Nosocomial pulmonary infection by antimicrobial-resistant bacteria of patients hospitalized in intensive care units: risk factors and survival.

The objectives of this study were to identify the risk factors of nosocomial pulmonary infection (NPI) in intensive care units (ICUs) associated with antimicrobial-resistant bacteria (NPI-ARB) and to compare survival after NPI-ARB with NPI due to antimicrobial-sensitive bacteria (NPI-ASB). We analysed data from a surveillance network monitoring nosocomial infections in 27 mixed ICUs in the south-east of France. NPI surveillance data were recorded for 628 patients with documented NPI. The patients were stratified into 2 groups by type of pneumonia: NPI-ASB (445 patients) vs. NPI-ARB (183 patients). Variables associated with NPI-ARB were identified++ by multivariate logistic regression. Survival was calculated using the Kaplan-Meier method. A medical condition for ICU admission [odds ratio (OR) 1.98, 95% confidence interval (95% CI) 1.35-2.91], transfer from another hospital ward [OR 1.66, 95% CI (1.14-2.42)], a colonized central venous catheter [OR 3.47, 95% CI (1.46-8.21)], a stay of [eight days [OR 1.02, 95% CI (1.01-1. 05)] and mechanical ventilation [OR 2.10, 95% CI (1.31-3.36)] were independent risk factors of NPI-ARB. Median survival was 35 days after NPI-ARB and 32 days after NPI-ASB (P=0.92). Survival after bacterial NPI was not associated with antimicrobial susceptibility.

Mild hyperlactatemia in stable septic patients is due to impaired lactate clearance rather than overproduction.

A prospective study was conducted on 34 stable septic patients to determine whether mild hyperlactatemia is a marker of lactate overproduction or an indicator of lactate underutilization during sepsis. Plasma lactate clearance and lactate production were evaluated by modeling the lactate kinetic induced by an infusion of 1 mmol/kg L-lactate over 15 min. The patients were divided in two groups depending on their blood lactate: < or = 1.5 mmol/L (n = 20, lactate = 1.2+/-0.2 mmol/L) or > or = 2 mmol/L (n = 10, lactate = 2.6+/-0.6 mmol/L). The hyperlactatemic patients had a lower lactate clearance (473+/-102 ml/kg/h) than those with normal blood lactate (1,002+/-284 ml/kg/h, p < 0.001), whereas lactate production in the two groups was similar (1,194+/-230 and 1,181+/-325 micromol/kg/h, p = 0.90). A second analysis including all the patients confirmed that the blood lactate concentration was closely linked to the reciprocal of lactate clearance (r2 = 0.73, p < 0.001) but not to lactate production (r2 = 0.03, p = 0.29). We conclude that a mild hyperlactatemia occurring in a stable septic patient is mainly due to a defect in lactate utilization.

Reliability of anion gap as an indicator of blood lactate in critically ill patients.

OBJECTIVE: To evaluate the sensitivity, specificity, and predictive values of an elevated anion gap as an indicator of hyperlactatemia and to assess the contribution of blood lactate to the serum anion gap in critically ill patients. DESIGN: Prospective study. SETTING: General intensive care unit of a university hospital. PATIENTS: 498 patients, none with ketonuria, severe renal failure or aspirin, glycol, or methanol intoxication. MEASUREMENTS AND RESULTS: The anion gap was calculated as [Na+]-[Cl-]-[TCO2]. Hyperlactatemia was defined as a blood lactate concentration above 2.5 mmol/l. The mean blood lactate concentration was 3.7 +/- 3.2 mmol/l and the mean serum anion gap was 14.3 +/- 4.2 mEq/l. The sensitivity of an elevated anion gap to reveal hyperlactatemia was only 44% [95% confidence interval (CI) 38 to 50], whereas specificity was 91% (CI 87 to 94 and the positive predictive value was 86% (CI 79 to 90). As expected, the poor sensitivity of the anion gap increased with the lactate threshold value, whereas the specificity decreased [for a blood lactate cut-off of 5 mmol/l: sensitivity = 67% (CI 58 to 75) and specificity = 83% (CI 79 to 87)]. The correlation between the serum anion gap and blood lactate was broad (r2 = 0.41, p < 0.001) and the slope of this relationship (0.48 +/- 0.026) was less than 1 (p < 0.001). The serum chloride concentration in patients with a normal anion gap (99.1 +/- 6.9 mmol/l) was comparable to that in patients with an elevated anion gap (98.8 +/- 7.1 mmol/l). CONCLUSIONS: An elevated anion gap is not a sensitive indicator of moderate hyperlactatemia, but it is quite specific, provided the other main causes of the elevated anion gap have been eliminated. Changes in blood lactate only account for about half of the changes in anion gap, and serum chloride does not seem to be an important factor in the determination of the serum anion gap.

Effect of continuous venovenous hemofiltration with dialysis on lactate clearance in critically ill patients.

OBJECTIVE: To evaluate the effect of continuous venovenous hemofiltration with dialysis on lactate elimination by critically ill patients. DESIGN: Prospective, clinical study. SETTING: Surgical intensive care unit of a university hospital. PATIENTS: Ten critically ill patients with acute renal failure and stable blood lactate concentrations. INTERVENTIONS: Two-stage investigation: a) measurement of lactate concentrations in samples of serum and ultradiafiltrate from patients receiving continuous venovenous hemofiltration with dialysis to calculate lactate clearance by the hemofilter; b) evaluation of total plasma lactate clearance by infusing sodium L-lactate (1 mmol/kg of body weight) over 15 mins. MEASUREMENTS AND MAIN RESULTS: Arterial lactate concentration was determined before, during, and after the infusion. Lactate elimination variables were calculated from the plasma curve using model-independent and model-dependent estimates (by software). At the end of the infusion, median blood lactate concentration increased from 1.4 mmol/L (range 0.8 to 2.6) to 4.8 mmol/L (range 2.4 to 5.7) and returned to 1.6 mmol/L (range 0.9 to 3.4) 60 mins later. The median total plasma lactate clearance was 1379 mL/min (range 753.7 to 1880.7) and the median filter lactate clearance was 24.2 mL/min (range 7.1 to 35.6). Thus, filter lactate clearance accounted for < 3% of total lactate clearance. CONCLUSIONS: Continuous venovenous hemofiltration with dialysis cannot mask lactate overproduction, and its blood concentration remains a reliable marker of tissue oxygenation in patients receiving this renal replacement technique.

[Transfusion of erythrocyte concentrates. An evaluation in anesthesia and intensive care]. / Transfusion de concentrés érythrocytaires. Une évaluation en anesthésie-réanimation.

OBJECTIVE: To assess the relevance of perioperative packed red blood cell (PRBC) transfusion practice at the University Hospital of Nice, compared with information from the consensus conference on red blood cell transfusion, held by the French Society of Anaesthesia and Intensive Care (SFAR) and the National Agency for the Development of Medical Evaluation (ANDEM) in December 1993. STUDY DESIGN: Retrospective case series analysis. PATIENTS: The study included 240 medical files of surgical patients, transfused in 1994 with PRBC, obtained by drawing of lots following a methodology recommended by ANDEM. METHOD: A reference list according to the statement of the consensus conference was designed for the various surgical specialities and the ICU in which PRBC had been transfused. It included the clinical and laboratory criteria which justified the transfusion, as well as the various categories of PRBC (phenotyped, cytomegalovirus negative, leukocyte-depleted, etc). Autotransfused PRBC were also considered. The data collected from the medical files of the 240 patients were compared with the reference list. RESULTS: In 84.6% of patients (203/240), the PRBC transfusion had been decided with reference either only to a haematocrit level below 0.27 or a level between 0.27 and 0.30 associated with clinical evidence of bad tolerance of blood loss, according to the reference list. A lack of compliance with the reference list occurred in 15.4% of patients (37/240), who had been transfused without any reference to a biological criterion. Another non compliance existed in 50% of patients (12/24) transfused with phenotyped PRBC and in 35.3% (6/17) of those transfused with leucocyte-depleted PRBC. An autotransfusion with PRBC had been carried out in 30.4% of patients (75/240). DISCUSSION: These deviations of transfusion practice from the consensus conference statement, which were more pronounced with phenotyped and leucocyte-depleted PRCB than conventional PRBC, resulted in the edition of a report, with an analysis of the causes of deviations and recommendations for all doctors of our institution prescribing blood transfusions. Another evaluation, extended also to the medical specialities of our hospital and including all blood derivates is planned for 1996.

[Effect of postoperative complications on nutritional status: therapeutic consequences]. / Retentissement des complications postopératoires sur l'état nutritionnel: conséquences thérapeutiques.

The occurrence of a postoperative complication represents an additional stress factor for patients and leads in many cases rapidly to a malnutrition status. Thus a nutritional support is required as soon as the foreseeable duration of starvation has a longer duration than one week. Considering its lower risk of septic complications and lower cost, enteral feeding should be initiated as soon as possible. Appraisal of caloric needs with standard formulas often leads to inappropriate nutritional management. Therefore the requirements should be assessed by indirect calorimetry if available. Nutritional support is a part of the management of a postoperative septic patient. It must be initiated when initial phase of haemodynamic instability is amended. Branched chain amino acids, medium chain triglycerides and other specific nutrients have failed to demonstrate a real clinical beneficial effect. In case of acute respiratory failure, nutritional support must be cautious with regard to caloric load, as carbohydrates may increase CO2 production and lipids may worsen hypoxaemia. In case of postoperative acute renal failure, nutritional management is facilitated by continuous haemofiltration techniques allowing an unlimited nutrient intake. Solutions containing only essential amino acids are not recommended. During severe acute pancreatitis, enteral feeding is indicated when ileus does not permit the use of the intestinal tract. Jejunal access must be preferred to stomach or duodenum. Lipid emulsions can be used safely if serum triglyceride concentrations remain below 4 g.L-1 during infusion and below 2 g.L-1 between infusions.

[Disseminated infection due to Scedosporium apiospermum in liver transplantation. Differential diagnosis from invasive aspergillosis]. / Infection disséminée à scedosporium apiospermum chez un transplanté hépatique. Un diagnostic différentiel de l'aspergillose invasive.

A case of fatal disseminated infection due to Scedosporium apiospermum occurring after liver transplantation is reported. Diagnosis was made at autopsy, as numerous fungal colonies were found in the lungs, heart, brain, kidney, spleen and liver. Scedosporium apiospermum was identified in pulmonary, cerebral and myocardial specimens by Sabouraud's glucose agar cultures. Infections due to Scedosporium (S. apiospermum ou Pseudallescheria boydii) occur in immunocompromised hosts, particularly after organ transplantation, and realize severe invasive fungal infection. Scedosporiosis is much more rare than aspergillosis and can be only identified by mycological study. This diagnosis is rarely performed during life time and allows an effective treatment by imidazoles.