Assessment of Clinical Practices for Crushing Medication in Geriatric Units.

OBJECTIVES: To assess the modification of the form of medication and evaluate staff observance of good clinical practices. DESIGN: One-day assessment of clinical practices. SETTING: 17 geriatrics units in the 3 Teaching Hospitals of Paris-Sud (APHP), France. PARTICIPANTS: Elderly in-patients with difficulties swallowing capsules and tablets. MEASUREMENTS: Assessment of target-patient prescriptions and direct observation of nurses' medical rounds. RESULTS: 155/526 in-patients (29.5%) were unable to swallow tablets or capsules: 98 (40.3%) in long-term care, 46 patients (23.8%) in the rehabilitation unit and 11 (12.2%) in the acute care unit (p = .005). In thirty-nine (27.3%) of the 143 prescriptions studied all tablets were safe to crush and all capsules were safe to open. In 104 cases, at least one medication could not be safely modified, including 26 cases (18.2%) in which none of the prescribed drugs were safe to crush or open. In 48.2% of the 110 medications that were crushed, crushing was forbidden, and presented a potential threat in 12.7% of cases or a reduced efficacy in 8.2% of cases. Crushing methods were rarely appropriate: no specific protective equipment was used (81.8%), crushing equipment was shared between patients without cleaning (95.1%), medications were spilled or lost (69.9%). The method of administration was appropriate (water, jellified water) in 25% of the cases, questionable (soup, coffee, compote, juice, cream) in 55% of the cases and unacceptable (laxative) in 21% of the cases. CONCLUSION: Management of drug prescriptions in patients with swallowing difficulties is not optimal, and may even have iatrogenic effects. In this study, 12.7% of the modifications of the drug form could have been harmful. Doctors, pharmacists and nurses need to reevaluate their practices.

[Patient-related factors and professional practices associated with postoperative pain]. / Facteurs explicatifs de la douleur post-opératoire: caractéristiques des patients et pratiques professionnelles.

BACKGROUND: Unrelieved postoperative pain is reported despite of widely defined standards for postoperative pain management. The objective of this study was to identify the relationship between patient characteristics, medical practices and outcomes (severe post-operative pain and patient satisfaction). METHODS: Using a cross-sectional observational study in 18 departments of adult surgery from 5 hospitals, medical records were audited according to a set of explicit criteria (patient characteristics and professional practices). Postoperative pain severity was measured with a 0 to 10 visual numerical scale and patient satisfaction using a six-level verbal rating scale (from very satisfied to very unsatisfied). The surgical procedures were classified into three levels of expected severe pain frequency (high, median, low). The relation between severity of pain, satisfaction on one hand, and process and patient characteristics on the other, was studied with chi(2)-test and logistic regression. RESULTS: 625 patients were included. 41.8% suffered from postoperative pain and 81.6% were satisfied. Pain measurement before leaving the postoperative anesthesia care unit (p<0.02) and protocols for analgesia in painful surgery (p<0.05) were associated with a lower frequency of pain. Three patient characteristics were associated with a higher frequency of severe postoperative pain: painful surgical procedure (p<0.001), mental pain (p<0.005), and preoperative pain (p<0.0001). The lack of administration of analgesia was a major explicative factor: 64% of patients with severe postoperative pain, did not receive all analgesics ordered. Patient satisfaction was higher when the patient was requested to notify pain (p<0.05) before surgery and lower after painful surgical procedures (p<0.05). CONCLUSION: There are two ways to improve pain management: first the quality of the analgesic prescription particularly for painful surgical procedures and secondly the administration of the prescribed analgesia.

Strategies for the diagnosis and treatment of bacteraemia in children with central venous catheters: an analysis.

The aim of this study was to analyse the diagnostic, empirical and therapeutic strategies adopted when a blood culture from a hospitalized child with a central venous catheter is 'positive', and to assess whether practices complied with the consensus adopted in our hospital, inspired by published recommendations. One hundred and ten cases of bacteraemia were studied prospectively. Investigations to determine whether the catheter was the cause of infection were carried out in 45% of cases, and the catheter was removed as recommended in 39% of cases. Of the patients that received empirical treatment, 56% received broad-spectrum antibiotics with no apparent clinical justification. Following susceptibility testing on the isolated strain, the antibiotic treatment was considered to be appropriate in 58% of cases. Overall, compliance with the consensus recommendations was poor. This was partly due to the high turnover rate of antibiotic prescribers.

Knowledge, attitudes, and behavior of the parents of asthmatic children in Maputo.

Asthma is increasing in frequency worldwide. The education of affected children and their parents is fundamental for the management of the disease. The aim of our study was to describe the knowledge, attitudes, and behavior of the parents of asthmatic children. We studied 152 adults accompanying asthmatic children to consultations in the pediatrics department of Maputo Central Hospital (Mozambique). In general, knowledge about asthma was poor: 11% of the adults thought that asthma was contagious and transmitted from person to person, and 4% thought that it was transmitted by contaminated food. More than half the parents thought that the child could not lead a normal life even during the periods between attacks. A large proportion of the parents thought that asthma could be cured by medical treatment in 7% of cases and by alternative treatment in 43% of cases. The precipitating factors were well identified by the adults, but they had an inaccurate perception of the symptoms of an asthma attack. The actions of the various classes of drugs used were poorly understood. Education programs for both the children and their parents should be developed to improve the management of asthmatic children. Surveys of this type facilitate the targeting of such programs.

Risk factors for asthma among children in Maputo (Mozambique).

BACKGROUND: Few studies have looked at risk factors for asthma in African children. We aimed to identify the risk factors associated with childhood asthma in Maputo (Mozambique). METHODS: This case-control study included 199 age-matched children (100 asthmatic and 99 nonasthmatic) who attended Maputo Central Hospital between January 1999 and July 2000. We collected information concerning their familial history of atopy, birth weight, environment and breast-feeding. Detailed information about morbidity and treatment was obtained for each asthmatic child. RESULTS: The children were aged between 18 months and 8 years; 60% were male. The asthmatic children were hospitalized more frequently than the nonasthmatic children (P < 0.0001). Most of the asthmatic children lived in the urban area of Maputo [odd ratio (OR) = 6.73, CI = 3.1-14.0, P < 0.0001], had a parental history of asthma (OR = 26.8, CI = 10.8-68.2, P < 0.0001) or rhinitis (OR = 4, CI = 1.2-13.3, P = 0.005), had at least parent who smoked and were weaned earlier than the nonasthmatic children (OR = 2.4, CI = 1.3-4.4, P < 0.001). CONCLUSION: Childhood asthma was strongly associated with a family history of asthma and rhinitis, the place of residence, having smokers as parents and early weaning from maternal breast milk. These results highlight the need to reassess the management of asthmatic children in Maputo.

Simple pediatric nutritional risk score to identify children at risk of malnutrition.

BACKGROUND: Although hospitalized children are at risk of malnutrition, routine screening of nutritional status has been hindered by lack of a validated nutritional assessment tool. OBJECTIVE: Our aim was to develop a simple pediatric nutritional risk score that could be used at hospital admission to identify patients at risk of acute malnutrition during hospitalization. DESIGN: Nutritional risk was assessed prospectively in 296 children. Anthropometric measurements, food intake, ability to eat and retain food, medical condition, and symptoms interfering with feeding (pain, dyspnea, and depression) were evaluated within 48 h of admission. Pathology was classified as mild (grade 1), moderate (grade 2), or severe (grade 3). The risk of weight loss was investigated with stepwise logistic regression. RESULTS: Weight loss during hospitalization occurred in 65% of the children and was >2% of admission weight in 45% of patients. Multivariate analysis indicated that food intake <50%, pain, and grade 2 and 3 pathologic conditions (P = 0.0001 for all) were associated with weight losses of >2%. The nutritional risk score ranged from 0 to 5 and was calculated by adding the values for the significant risk factors as follows: 1 for food intake <50%, 1 for pain, 1 for grade 2 pathologic condition, and 3 for grade 3 pathologic condition. A score of 1 or 2 indicated moderate risk and a score >/=3 indicated high risk of malnutrition. CONCLUSIONS: This simple score is suitable for routine use to identify patients at risk of malnutrition during hospitalization. Implementation may prevent hospital-acquired malnutrition.

[Impact of French consensus conference concerning the follow-up of patients surgically treated for stage I melanoma among French dermatologists and oncologists]. / Impact de la conférence de consensus sur le suivi des malades opérés de mélanome de stade I chez les dermatologues et cancérologues français.

INTRODUCTION: Our aim was to assess the impact of the 1995 French Consensus Conference (CC) on the follow up of patients surgically treated for WHO stage I (AJCC/UICC stages IA to IIB) melanoma, two years after the recommendations had been provided to French dermatologists and oncologists by direct mailing and literature. Prior to this CC, a study of French dematologists' intentions of practice and dermatologists and oncologists effective practices had revealed a lack of homogeneity and the prescription of many paraclinical tests. MATERIAL AND METHODS: In 1997, we sent a questionnaire similar to 1995's one to French dermatologists (3585 practitioners) and oncologists (686), with a pre-paid envelop for the response. The statistical analysis compared these results with those of 1995 for dermatologists, and the results for dermatologists and oncologists using chi(2) test. RESULTS: The response rate was 29 p. 100 for dermatologists, 15 p. 100 for oncologists. Only the number of dermatologists following patients in private practice was increased. Prescriptions of paraclinical tests by dermatologists during initial investigation as well as during follow up dramatically decreased (-30 p. 100 to -50 p. 100), mainly for thoracoabdominal and brain computerized tomography scans and biological tests, to a lesser extent for chest X-rays and abdominal ultrasonographies. Prescriptions of paraclinical tests were higher among oncologists. The frequency of clinical surveillance in 1997 was more often as recommended. Detection of a second melanoma in the patients and their family had improved. However, oncologists' intentions of practice complied less to the CC as compared to dermatologists. DISCUSSION: This study clearly showed an impact of the CC in French dermatologists' intentions of practice leading to both an improvement of patient follow up and a reduction in its cost. This impact was not as great among oncologists.

[Implication of French general practitioners in the follow-up of patients surgically treated for stage I melanoma]. / Implication des médecins généralistes dans le suivi des malades opérés de mélanome de stade I.

INTRODUCTION: Our aim was to assess the implication of French general practitioners in the follow up of patients surgically treated for stage I melanoma 2 years after the publication of the 1995 French consensus conference recommendations. MATERIAL AND METHODS: In 1997, we sent a questionnaire to all the general practitioners of Hauts-de-Seine department (n = 1000). In that department, specific training on this topic had been conducted in 1996. RESULTS: The response rate was 12.4 p. 100. Follow up was performed in association with a dermatologist or a oncologist by 97 p. 100. There was a high rate of non-response for questions concerning follow up which reached 30.4 p. 100 for thick melanomas. DISCUSSION: Because of the low response rate, the interpretation of these results must be interpreted with precaution. Dermatologists seem to be the general practitioners' preferred correspondents for patients with melanoma.

[Audit of the management of postoperative pain]. / Audit de la prise en charge de la douleur postopératoire.

OBJECTIVE: The aim of this study was to assess the incidence and severity of postoperative pain in patients undergoing operations in various surgery clinics in the Assistance Publique des Hôpitaux de Paris (AP-HP) and to evaluate management of pain during the 24 hours following surgery. METHODS: Data from surgical and anesthesia observation sheets and from patient complaints collected in a one-day external audit were obtained for 96 surgery clinics in the AP-HP. RESULTS: At the time of surgery, most patients were receiving opioids, especially fentanyl: low dose ( < 1 microgram/kg/h) was given in 17.1% of the patients and regional anesthesia was used in 13%. In 95% of the cases, postoperative orders were written by anesthesiologists. Initial orders were modified according to patient response in 11.8% of the cases. "On demand" prescriptions were used in 10% of the orders. Patient controlled analgesia and regional analgesia were not routine techniques (2 and 0% respectively). Finally, 37.8% of the patients were given a single prescription of a step-1 drug (e.g. propacetamol i.v.), 25.9% a step-2 drug either alone or in combination with a step-1 drug, and 28.9% of the patients were given strong opioids at least once. CONCLUSIONS: For all types of drugs, dosage level was considered as correct in 86.5% of the cases. For approximately 10% of the opioid prescriptions, an ineffective dose was used. The interval between doses was too long in 54.1% of the prescriptions for at least one drug (e.g. for peripheral analgesia with propacetamol). The incidence of severe pain was 46.4%, especially after abdominal, high urologic and back surgery.

[Unilateral inguinal hernia in infants: costs, risks and benefits of herniography? Methodology]. / Hernie inguinale unilatérale de l'enfant de moins de deux ans: coût, risques et bénéfices de la herniographie? Méthodologie.

AIM: To assess the validity and the interest to health of systematic herniography in cases of unilateral inguinal hernia in children under two years of age. METHOD: Decision theory was used to assess the effect of herniography on individual health by estimating gonadic benefit and establishing a benefit-risk ratio, and on collective health by the use of cost-effectiveness analysis. RESULTS: a decision tree and algorithms were developed. DISCUSSION: Decision analysis is used in complex medical decision making, clarifying choices and subdividing a problem into several more manageable sub-problems. The threshold approach pinpoints factors requiring more information.

[Unilateral inguinal hernia in infants: costs, risks and benefits of herniography? Results]. / Hernie inguinale unilatérale de l'enfant de moins de deux ans: coût, risques et bénéfices de la herniographie? Résultats.

AIM: To assess the advantages of systématic herniography in cases of unilateral inguinal hernia in infants. METHOD: Decision analysis presented in the first part of this article was used. A preliminary retrospective study of 348 cases as well as a literature review were utilized to determine the probabilities required in order to create and run the decision aid algorithm. Gonadic benefit was used as the health indicator. RESULTS: For males, gonadic benefit procured by the herniography depends on the risk of strangulation in cases of groin hernia and on the frequency of testicular atrophy after inguinal hernioplasty. The evaluation of these two elements largely determines the choice of medical and surgical practices. For a 0.44% risk of post-operative testicular atrophy and a risk of strangulated hernia estimated at 20%, the cost-effectiveness ratio is FF, 199681 to save a testicle. One testicle is saved every 455 herniographies, with 24 possible post-examination complications. For female, herniography provides no gonadic benefit. DISCUSSION: Decision analysis permits the quantification of results, leading to improved clinical judgement and facilitating the evaluation of medical practice.

[Medical and social factors in the orientation of patients with AIDS after discharge]. / Facteurs médico-sociaux d'orientation des malades du SIDA après hospitalisation.

The objectives of this cohort survey performed in acute care patients were to identify and to describe HIV patients needing long-term care with or without daily assistance (home care of health care institutions). This exhaustive sample was recruited from among the hospitalized AIDS patients of fifteen departments of Assistance Publique-Hôpitaux de Paris; 24% of them required post-discharge medical care (home care or health care institutions). The effects of different factors were assessed to explain the choice of home care or various health care institutions: medical reasons, type of care required, functional disability, and socio-economic conditions. Home care patients had complex care needs, parenteral treatments mainly related to Cytomegaloviral retinitis, and poor functional status. They had a favourable socio-economic environment and help with household activities. Two groups of patients were sent to health care institutions. The first, comprised patients in very poor functional or/and mental conditions, especially in the terminal stage of central nervous system illness. The second, included patients with acceptable functional status, multiple pathologies, and poor socio-economic conditions. After adjustment, significant factors influencing the possibility of home care were: a previous successful home care experience and a high educational level. The factors limiting the possibility of home care were important neurologic symptoms, drug use, living alone and poor lodgings. The results of this study suggest that it would be necessary to increase the availability of long term care facilities for persons with AIDS and develop earlier medico-social follow-up, in order to anticipate the problems related to bad socio-economic conditions.

[Evaluation of hospital care. An experiment at the Public Assistance Hospitals in Paris]. / L'évaluation des soins à l'hôpital. Une expérience à l'Assistance Publique-Hôpitaux de Paris.

Since 1990 the Assistance Publique--Hôpitaux de Paris (AP-HP) developed a policy of health care assessment in agreement with the implications of the law of July 31, 1991. The department of Evaluation of health care, in close collaboration with the local Committees which operate in most of the hospitals of AP-HP, performed during the last three years about fifty studies dealing with two main topics: professional procedures and quality of care. Through three specific selected studies, the authors emphasize the requirements of an assessment policy to efficiently contribute to the improvement of quality of care.

[Evaluation in gynecology and obstetrics. Propositions for routine evaluation of professional practices]. / Evaluation en gynécologie-obstétrique. Propositions pour une évaluation de routine des pratiques professionnelles.

All the scientific prerequisites for auditing Gynaecology-Obstetrics clinics are currently available. Nevertheless, it is often difficult to usefully evaluate routine decision making. The aim of this paper was to offer matter for thought concerning the choice of methods and themes to be used in evaluating routine management in Gynaecology-Obstetrics clinics. Several methods are discussed, including monitoring synthetic indicators and complex evaluation of routine decision making (relationship between recruitment, practices and results). Details of this latter method were presented with several examples: prematurity prevention, perinatal mortality and morbidity, screening tests and antenatal diagnosis, cesarean section.

Intra-uterine growth: a comparison of longitudinal and cross-sectional approaches.

The great majority of the fetal growth curves are constructed through a cross-sectional approach. Before the use of ultra-sonography, fetal growth was first evaluated from birthweights of infants born at different gestational ages. More recently, curves were established for different ultrasonographic parameters which combination can provide an immediate but imperfect evaluation of fetal weight. All the curves used as standards of normal growth derive from cross-sectional studies. Several longitudinal studies of fetal growth exist, with two aspects. The first method is to make serial measurements at special intervals, among a group of fetuses with known dates of conception, in order to determine average longitudinal curves. The aim of the standards of fetal growth is obstetric management and the threshold of a percentile, for instance the tenth, of an ultra-sonographic parameter can define the intra-uterine growth retardation. The result of the fetal growth is evaluated with the standards of birthweight which define the small for gestational age infant. Another longitudinal approach is the use of a mathematical growth model to establish an individual growth curve, each fetus is then its own control. This last approach still belongs to the research field.