From COVID-19 Pandemic to Patient Safety: A New "Spring" for Telemedicine or a Boomerang Effect?

During the Covid-19 health emergency, telemedicine was an essential asset through which health systems strengthened their response during the critical phase of the pandemic. According to the post-pandemic economic reform plans of many countries, telemedicine will not be limited to a tool for responding to an emergency condition but it will become a structural resource that will contribute to the reorganization of Healthcare Systems and enable the transfer of part of health care from the hospital to the home-based care. However, scientific evidences have shown that health care delivered through telemedicine can be burdened by numerous ethical and legal issues. Although there is an emerging discussion on patient safety issues related to the use of telemedicine, there is a lack of reseraches specifically designed to investigate patient safety. On the contrary, it would be necessary to determine standards and specific application rules in order to ensure safety. This paper examines the telemedicine-risk profiles and proposes a position statement for clinical risk management to support continuous improvement in the safety of health care delivered through telemedicine.

Congenital anomalies among live births in a polluted area. A ten-year retrospective study.

BACKGROUND: Congenital anomalies and their primary prevention are a crucial public health issue. This work aimed to estimate the prevalence of congenital anomalies in Brindisi, a city in southeastern Italy at high risk of environmental crisis. METHODS: This research concerned newborns up to 28 days of age, born between 2001 and 2010 to mothers resident in Brindisi and discharged with a diagnosis of congenital anomaly. We classified cases according to the coding system adopted by the European Network for the Surveillance of Congenital Anomalies (EUROCAT). Prevalence rates of congenital anomalies in Brindisi were compared with those reported by EUROCAT. Logistic regression models were adapted to evaluate the association between congenital anomalies and municipality of residence of the mother during pregnancy. RESULTS: Out of 8,503 newborns we recorded 194 subjects with congenital anomalies (228.2/10,000 total births), 1.2 times higher than the one reported by the EUROCAT pool of registries. We observed 83 subjects with congenital heart diseases with an excess of 49.1%. Odds Ratios for congenital heart diseases significantly increased for newborns to mothers resident in Brindisi (OR 1.75 CI 95% 1.30-2.35). CONCLUSIONS: Our findings indicated an increased prevalence of Congenital Anomalies (especially congenital heart diseases) in the city of Brindisi. More research is needed in order to analyze the role of factors potentially involved in the causation of congenital anomalies.

[Use of the new Italian version of the International Classification of Diseases-Clinical Modification (ICD-9-CM) for the information system of immunization health services]. / Utilizzo della nuova versione italiana 2009 della International Classification of Diseases-Clinical Modification (ICD-9-CM) per il sistema informativo dei servizi sanitari dedicati alle vaccinazioni.

Compared to the previous one, the recently updated Italian version of the International Classification of Diseases - Clinical Modification (ICD-9-CM) includes new codes for the description of medical-related vaccinations procedures. In this work the new codes are described and the Classification is proposed as a possible tool for storing electronic information systems of immunization health services.

Prevalence of the congenital long-QT syndrome.

BACKGROUND: The prevalence of genetic arrhythmogenic diseases is unknown. For the long-QT syndrome (LQTS), figures ranging from 1:20 000 to 1:5000 were published, but none was based on actual data. Our objective was to define the prevalence of LQTS. METHODS AND RESULTS: In 18 maternity hospitals, an ECG was performed in 44 596 infants 15 to 25 days old (43 080 whites). In infants with a corrected QT interval (QTc) >450 ms, the ECG was repeated within 1 to 2 weeks. Genetic analysis, by screening 7 LQTS genes, was performed in 28 of 31 (90%) and in 14 of 28 infants (50%) with, respectively, a QTc >470 ms or between 461 and 470 ms. A QTc of 451 to 460, 461 to 470, and >470 ms was observed in 177 (0.41%), 28 (0.06%), and 31 infants (0.07%). Among genotyped infants, disease-causing mutations were found in 12 of 28 (43%) with a QTc >470 ms and in 4 of 14 (29%) with a QTc of 461 to 470 ms. One genotype-negative infant (QTc 482 ms) was diagnosed as affected by LQTS on clinical grounds. Among family members of genotype-positive infants, 51% were found to carry disease-causing mutations. In total, 17 of 43 080 white infants were affected by LQTS, demonstrating a prevalence of at least 1:2534 apparently healthy live births (95% confidence interval, 1:1583 to 1:4350). CONCLUSIONS: This study provides the first data-based estimate of the prevalence of LQTS among whites. On the basis of the nongenotyped infants with QTc between 451 and 470 ms, we advance the hypothesis that this prevalence might be close to 1:2000. ECG-guided molecular screening can identify most infants affected by LQTS and unmask affected relatives, thus allowing effective preventive measures.

[Evaluation of hospital admissions for angiocardiographic procedures in patients with cardiovascular disease (DRG 124): a retrospective study in four Rome hospitals (Italy)]. / Analisi dei ricoveri ordinari finalizzati all'esecuzione di esami angiocardiografici per patologie cardiovascolari attributi al DRG 124: studio retrospettivo in quattro ospedali di Roma.

The aim of this study was to evaluate hospital admissions assigned to DRG 124 because attributable to the diagnosis and therapy of cardiovascular diseases and the performance of an angiocardiographic exam with contrast and/or cardiac catheterism. As part of the hospital activity evaluations performed by the Lazio Region between 1 January 2002 and 30 June 2005 in four healthcare institutions in the Rome metropolitan area, 136 admissions assigned to DRG 124 were evaluated. An evaluation grid was used to verify information recorded in the hospital discharge forms and hospital medical records for these admissions. Overall 89% (121/136) of medical records were found to be incongruent with the corresponding hospital discharge form and 53% of admissions (72/136) were reassigned a different DRG after evaluation. In most of these cases (n=54; 76%) the selection of a different DRG was required because an incorrect main diagnosis had originally been chosen. The mean relative weight of admissions in which DRG reassignment was required was 1.4189 before recoding and 0.7545 after these were assigned to a new DRG.

[Survey to evaluate fees charged and time limits for issuing a medical records's paper copy by hospitals of Lazio Region (Italy)]. / Indagine sui costi e sui tempi di consegna di rilascio agli aventi diritto della copia cartacea della cartella clinica nelle strutture ospedaliere del Lazio.

Aim of the present study was to evaluate the different fees charged for providing paper copies of medical records and time limits for their delivery. The analysis involved all the public and private hospitals in Lazio Region (Italy). The authors administered a short telephone questionnaire to the medical affairs direction of all the hospitals in the survey. In 94.6% of cases (n=106 hospitals) the requested information have been provided. Data analysis showed that average fee charged for issuing copies of medical records was, respectively, 13.90 vs 12.66 euro for inpatient and day hospital. Average time limits for dealing with a request for paper copies of medical records was 24.2 days, less than time established by Italian Law (30 days). The survey showed, however, a huge variability that concerns both the fees and times of issue of medical charts.

[Development of classification and payment system of in patient hospital admissions in the United States: introduction of Medicare Severity Diagnosis-Related Groups (MS-DRGs) and the Present On Admission (POA) indicator]. / Evoluzione del sistema di classificazione e di pagamento dei ricoveri per acuti negli Stati Uniti: introduzione dei Medicare Severity - Diagnosis Related Groups (MS-DRGs) e del Present On Admission (POA) indicator.

In the United States, from Fiscal Year 2008 (october 1, 2007-september 30, 2008), two important innovations have been introduced in health insurance program Medicare: 1) Centers for Medicare & Medicaid Services (CMS) proposes to refine the current DRG system by implementing Medicare-Severity DRGs (MS-DRGs), increasing the number of DRGs from 538 to 745. In addition, CMS has undertaken an overhaul of today's complication and comorbidity (CC) list and created up to three tiers of payment for each DRG based on the presence of: a major complication or comorbidity (MCC), a complication or comorbidity, or no complication or comorbidity; 2) the Federal Government, in compliance with the Deficit Reduction Act of 2005, has required secondary diagnosis reporting for all Medicare patients at the time of admission by a Present On Admission (POA) indicator. The authors describe the main characteristics of the new MS-DRG system and POA indicator and their potential impact on Italian Public Health system.

[A retrospective study to an evaluation of the quality of Uniform Hospital Discharge Data Set regarding discharge with death of the patient attributed to a Diagnosis Related Group with a low Relative Weight; retrospective study in some hospitals in Rome [corrected]]. / Valutazione della qualità della codifica della scheda di dimissione ospedaliera relativamente a ricoveri esitati con il decesso del paziente attribuiti ad un DRG a basso peso relativo: studio retrospettivo in alcuni ospedali di Roma.

Aim of the present study is to evaluate the quality of medical record and Uniform Hospital Discharge Data Set (UHDDS), regarding admissions with death of the patient assigned to a Diagnosis Related Group (DRG) with a Relative Weight (RW) less than 1; the authors suggest that these admissions involve a more expensive hospital treatment if compared to admissions with favorable outcome and, therefore, the attribution of a DRG with RW more than 1 might be ascribed to an incorrect compilation of UHDDS. The admissions with the death of the patient, carried out between July 2002 and December 2002, in 11 different Rome hospitals located within the territory of two Local Health Units, have been split into 2 groups: admissions assigned to a DRG with RW less than 1 (group 1) and more than 1 (group 2). Afterward, two doctors of the Regional System of External Controls have required and examined the medical records of the group 1 (n= 57) using an evaluating format to verify the accuracy of UHDDS information. In the 91.0% (n=51) of the cases the UHDDS coding have been considered inadequate. In the 96.2% of the cases (n=49) the principal diagnosis has not been correctly coded while, in the 69.2% of the cases (n=36), at least one of the secondary diagnosis has been incorrectly reported. Medium RW rose from 0,7893 to 1,4354 after controllers' review and assignment of the new DRG. The results have confirmed the initial hypothesis and pointed out how an incorrect compilation of the UHDDS might compromise its validity under a statistic and epidemiologic point of view and produce significant repercussions under the economic one.

Indications and limitations for a neonatal pulse oximetry screening of critical congenital heart disease.

AIMS: Critical congenital cardiovascular malformations (CCVMs) require surgical correction during the first month of life, physical examination is unable to detect >50% of affected infants. An oximetry screening has been previously proposed. Our aim was to verify the usefulness and consistency of a pulse oximetry screening for early detection of CCVMs in a small size nursery. METHODS: A single determination of SpO2 was performed on 5292 consecutive apparently healthy newborns, discharged from nursery at a median age of 72 h during the period May 1, 2000 and November 30, 2004. Infants showing signs of congenital heart disease before the screening and those with a prenatal diagnosis were excluded. Cardiac ultrasound was performed on all infants with SpO2< or =95% at >24 h. The accuracy of the screening in identifying CCVMs was assessed by receiver-operating characteristic (ROC) curves analysis. RESULTS: We found 2 (0.038%) true positives, 1 (0.019%) false negative, 1 (0.019%) false positive, and 5288 (99.92%) true negatives. Prevalence of critical CCVMs was 1 in 1764. Clinical follow-up showed no evidence of CCVMs in the negative cases. A pulse-oximetry cut-off value of < or =95% showed 66.7% sensitivity (95% CI: 11.6-94.5), 100% specificity (95% CI: 99.9-100.0), 50% positive predictive value, 100% negative predictive value and AUC of 0.833 (standard error: 0.145) (95% CI: 0.823 to 0.843) in identifying CCVMs. CONCLUSIONS: Our findings indicate that pulse oximetry is a non-invasive and specific screening tool for an early detection of CCVMs, and is easily applicable to a small size nursery.

[A retrospective study to evaluate the quality of medical charts and discharge abstracts in several Rome hospitals]. / Qualità della cartella clinica e della scheda di dimissione ospedaliera: studio retrospettivo in alcuni ospedali di Roma.

Previous studies have shown that the quality of medical records is not uniform across Italian hospitals. Between March 2002 and January 2003, we assessed the quality of 6,215 medical charts regarding admissions to 11 different Rome hospitals in the year 2001. The hospitals were located within the territory of the ROMA "A" and ROMA "C" Local Health Units. The following were evaluated: 1) organization, format and lay-out of medical records; 2) medical chart and discharge abstract compilation; 3) ICD-9-CM coding accuracy. The quality of medical records and of discharge abstracts, as judged especially by their format and by the completeness, accuracy, congruency and clearness of the reported information, varied extensively among the different wards and hospitals. The main problems were identified and possible solutions are discussed. We suggest that improved quality of medical records and discharge abstracts may be promoted through: 1) use of a standardized format for medical records in all wards of the same hospital; a supplement may eventually account for the characteristic requirements of specialist wards; 2) adoption of guidelines for medical record-keeping and of a code of conduct for discharge abstract coders; 3) use of a new discharge abstract form that favours more accurate ICD-9-CM coding and that allows more effective gathering of clinical data for epidemiological purposes.

Prolonged fetal bradycardia as the presenting clinical sign in Streptococcus agalactiae chorioamnionitis.

Group B Streptococcus remains a leading infectious cause of neonatal morbidity and mortality. We report a case of a 37 weeks' gestation infant with severe birth asphyxia, status epilepticus and GBS chorioamnionitis, in which a prolonged fetal bradycardia was the only prenatal clinical sign.

Skin reflectance changes in preterm infants with patent ductus arteriosus.

INTRODUCTION: Patent ductus arteriosus (PDA) is a common complication in preterm infants. While two-dimensional echocardiography is the method of choice for diagnosing a PDA, clinical signs are known to be of limited value. STUDY DESIGN: Haemodynamically significant PDA (hs-PDA) was defined as a ductal left-to-right shunt with elevated left atrial/aortic root ratio ( > 1.6:1), a ductal diameter > 2 mm, retrograde diastolic flow exceeding 30% of the anterograde flow and anterograde peak diastolic flow velocity in left pulmonary artery > 50 cm/s. A hs-PDA may affect the cerebral circulation and skin color is known to be related to local perfusion. In this study, we tested the value of a caudal-to-cephalic skin reflectance differential in detecting preterm infants with hs-PDA. The study was blinded and prospective. SUBJECTS: Fifteen infants with a hs-PDA (M: 8, F: 7; gestational age: 28.0 +/- 2.0 weeks, birth weight: 880 +/- 130 g) and 15 gender- and gestational age-matched infants without a haemodynamically significant PDA (M: 8, F: 7; gestational age: 28.2 +/- 2.3 weeks, birth weight: 885 +/- 135 g) participated to the study. OUTCOME MEASURE: Skin reflectance measurements were performed using a reflectance spectrophotometer (CM-2600d/2500d, Minolta, Osaka, Japan). Sole ("postductal" site) to forehead ("preductal" site) skin reflectance ratio (caudal-to-cephalic ratio). RESULTS: hs-PDA infants showed significantly lower forehead light reflectance values on for the whole visible spectrum (p < or = 0.043) with the exception of 580-590 nm (p = 0.058), whereas no statistically significant differences were observed for the sole skin reflectance between the two groups in the examined visible spectrum. Consequently, hs-PDA infants showed a significantly higher caudal to cephalic ratio in the 410-430 nm (p < or = 0.042), 460-530 nm (p < or = 0.027) and 590-700 nm (p < or = 0.011) wavelength ranges. CONCLUSIONS: These findings may provide a previously unrecognised clinical marker for haemodynamically significant PDA in preterm infants, thus predicting those preterm infants who may require intervention for PDA.

Postural hypotension in hypertensive patients.

BACKGROUND: The association between orthostatic hypotension and supine hypertension (Hypo-Hyper) has been reported in previous studies on selected populations. The present longitudinal study aimed to characterize the haemodynamic patterns, comorbidity, prognostic implications and eventual effect of therapy in patients with the Hypo-Hyper pattern. METHODS: Ambulatory blood pressure monitoring (AMAP) and clinical evaluation were performed on 615 consecutive patients recruited from the Hypertension Clinics of five Italian Hospitals: 34 patents were identified as Hypo-Hyper, and underwent 10-month follow-up. RESULTS: The incidence of the Hypo-Hyper pattern was 5.5% in the hypertensives studied. Hypo-Hyper was more frequent in the elderly (mean age 58 years), and the affected population exhibited different kinds of underlying pathologies. Multivariate analysis showed no association between antihypertensive treatment and Hypo-Hyper pattern. Patients with AMAP features of higher blood pressure values at night-time than at daytime displayed higher rates of myocardial hypertrophy and pacemaker implantation during the follow-up. CONCLUSIONS: Although the study design did not aim to identify any pathophysiological mechanism for Hypo-Hyper pattern, these first data show that the Hypo-Hyper association is the effect of a particular subtype of hypertension, with significantly different prognostic implications.