Immunoelectron microscopical identification of the uncoupling protein in brown adipose tissue mitochondria.

The distribution of the uncoupling protein (UCP) in brown adipocyte mitochondria of the hibernant Muscardinus avellanarius was obtained by ultrastructural immunocytochemistry. In both cryosections and sections of Lowicryl-embedded material UCP was localized in the mitochondrial cristae of brown adipocytes, but not in liver mitochondria. It should now be possible to easily identify the morphology of cells committed to BAT differentiation in the tissue as well as in cell culture.

Cultural competency of health-care providers in a Swiss University Hospital: self-assessed cross-cultural skillfulness in a cross-sectional study.

BACKGROUND: As the diversity of the European population evolves, measuring providers' skillfulness in cross-cultural care and understanding what contextual factors may influence this is increasingly necessary. Given limited information about differences in cultural competency by provider role, we compared cross-cultural skillfulness between physicians and nurses working at a Swiss university hospital. METHODS: A survey on cross-cultural care was mailed in November 2010 to front-line providers in Lausanne, Switzerland. This questionnaire included some questions from the previously validated Cross-Cultural Care Survey. We compared physicians' and nurses' mean composite scores and proportion of "3-good/4-very good" responses, for nine perceived skillfulness items (4-point Likert-scale) using the validated tool. We used linear regression to examine how provider role (physician vs. nurse) was associated with composite skillfulness scores, adjusting for demographics (gender, non-French dominant language), workplace (time at institution, work-unit "sensitized" to cultural-care), reported cultural-competence training, and cross-cultural care problem-awareness. RESULTS: Of 885 questionnaires, 368 (41.2%) returned the survey: 124 (33.6%) physicians and 244 (66.4%) nurses, reflecting institutional distribution of providers. Physicians had better mean composite scores for perceived skillfulness than nurses (2.7 vs. 2.5, p < 0.005), and significantly higher proportion of "good/very good" responses for 4/9 items. After adjusting for explanatory variables, physicians remained more likely to have higher skillfulness (β = 0.13, p = 0.05). Among all, higher skillfulness was associated with perception/awareness of problems in the following areas: inadequate cross-cultural training (β = 0.14, p = 0.01) and lack of practical experience caring for diverse populations (β = 0.11, p = 0.04). In stratified analyses among physicians alone, having French as a dominant language (β = -0.34, p < 0.005) was negatively correlated with skillfulness. CONCLUSIONS: Overall, there is much room for cultural competency improvement among providers. These results support the need for cross-cultural skills training with an inter-professional focus on nurses, education that attunes provider awareness to the local issues in cross-cultural care, and increased diversity efforts in the work force, particularly among physicians.

Evaluation of the impact of a therapeutic drug monitoring program in a Swiss University Hospital

Background and objective: Therapeutic Drug Monitoring (TDM) has been introduced early 1970 in our hospital (CHUV). It represents nowadays an important routine activity of the Division of Clinical Pharmacology and Toxicology (PCL), and its impact and utility for clinicians required assessment. This study thus evaluated the impact of TDM recommendations in terms of dosage regimen adaptation. Design: A prospective observational study was conducted over 5 weeks. The primary objective was to evaluate the application of our TDM recommendations and to identify potential factors associated to variations in their implementation. The secondary objective was to identify pre-analytical problems linked to the collection and processing of blood samples. Setting: Four representative clinical units at CHUV. Main outcome measure: Clinical data, drug related data (intake, collection and processing) and all information regarding the implementation of clinical recommendations were collected and analyzed by descriptive statistics. Results: A total of 241 blood measurement requests were collected, among which 105 triggered a recommendation. 37% of the recommendations delivered were applied, 25 % partially applied and 34% not applied. In 4% it was not applicable. The factors determinant for implementation were the clinical unit and the mode of transmission of the recommendation (written vs oral). No clear difference between types of drugs could be detected. Pre-analytical problems were not uncommon, mostly related to completion of request forms and delays in blood sampling (equilibration or steady-state not reached). We have identified 6% of inappropriate and unusable drug level measurements that could cause a substantial cost for the hospital. Conclusion: This survey highlighted a better implementation of TDM recommendations in clinical units where this routine is well integrated and understood by the medical staff. Our results emphasize the importance of communication with the nurse or the physician in charge, either to transmit clinical recommendations or to establish consensual therapeutic targets in specific conditions. Development of strong partnerships between clinical pharmacists or pharmacologists and clinical units would be beneficial to improve the impact of this clinical activity.

Consommation d'alcool à risque dans un collectif de patients de la Policlinique médicale universitaire de Lausanne [High risk alcohol consumption in a sample of patients of the Lausanne University Medical Polyclinic].

OBJECTIVES AND METHODS: This study indicates the prevalence, the characteristics, and the screening methods of patients with at risk alcohol drinking at the University Medical Clinic of Lausanne. RESULTS: The results reported demonstrate that one patient out of six is a drinker at risk without criteria for alcohol-dependance. The questionnaire AUDIT (Alcohol Use Disorders Identification Test) with a cut-off of five points seems to be the best screening test for at risk alcohol consumption. CONCLUSIONS: The high prevalence of at risk drinking in this study, combined with scientific evidence of the efficiency of brief interventions in changing drinking habits, emphasises the importance of alcohol screening for all patients attending outpatient medical settings.

Underreporting of needlestick and sharps injuries among healthcare workers in a Swiss University Hospital.

OBJECTIVES: To determine 1) rates of needlestick and sharps injuries (NSSIs) not reported to occupational health services, 2) reasons for underreporting and 3) awareness of reporting procedures in a Swiss university hospital. MATERIALS AND METHODS: We surveyed 6,367 employees having close clinical contact with patients or patient specimens. The questionnaire covered age, sex, occupation, years spent in occupation, history of NSSI during the preceding twelve months, NSSI reporting, barriers to reporting and knowledge of reporting procedures. RESULTS: 2,778 questionnaires were returned (43.6%) of which 2,691 were suitable for analysis. 260/2,691 employees (9.7%) had sustained at least one NSSI during the preceding twelve months. NSSIs were more frequent among nurses (49.2%) and doctors performing invasive procedures (IPs) (36.9%). NSSI rate by occupation was 8.6% for nurses, 19% for doctors and 1.3% for domestic staff. Of the injured respondents, 73.1% reported all events, 12.3% some and 14.6% none. 42.7% of doctors performing invasive procedures (IPs) underreported NSSIs and represented 58.6% of underreported events. Estimation that transmission risk was low (87.1%) and perceived lack of time (34.3%) were the most common reasons for non-reporting. Regarding reporting procedures, 80.1% of respondents knew to contact occupational health services. CONCLUSION: Doctors performing IPs have high rates of NSSI and, through self-assessment that infection transmission risk is low or perceived lack of time, high rates of underreporting. If individual risk analyses underestimate the real risk, such underreporting represents a missed opportunity for post-exposure prophylaxis and identification of hazardous procedures. Doctors' training in NSSI reporting merits re-evaluation.

Financial impact of introducing the Swiss-DRG reimbursement system on potentially avoidable readmissions at a university hospital.

QUESTION UNDER STUDY: Thirty-day readmissions can be classified as potentially avoidable (PARs) or not avoidable (NARs) by following a specific algorithm (SQLape®). We wanted to assess the financial impact of the Swiss-DRG system, which regroups some readmissions occurring within 18 days after discharge within the initial hospital stay, on PARs at our hospital. METHODS: First, PARs were identified from all hospitalisations recorded in 2011 at our university hospital. Second, 2012 Swiss-DRG readmission rules were applied, regrouped readmissions (RR) were identified, and their financial impact computed. Third, RRs were classified as potentially avoidable (PARRs), not avoidable (NARRs), and others causes (OCRRs). Characteristics of PARR patients and stays were retrieved, and the financial impact of PARRS was computed. RESULTS: A total of 36,777 hospitalisations were recorded in 2011, of which 3,140 were considered as readmissions (8.5%): 1,470 PARs (46.8%) and 1,733 NARs (53.2%). The 2012 Swiss-DRG rules would have resulted in 910 RRs (2.5% of hospitalisations, 29% of readmissions): 395 PARRs (43% of RR), 181 NARRs (20%), and 334 OCRRs (37%). Loss in reimbursement would have amounted to CHF 3.157 million (0.6% of total reimbursement). As many as 95% of the 395 PARR patients lived at home. In total, 28% of PARRs occurred within 3 days after discharge, and 58% lasted less than 5 days; 79% of the patients were discharged home again. Loss in reimbursement would amount to CHF 1.771 million. CONCLUSION: PARs represent a sizeable number of 30-day readmissions, as do PARRs of 18-day RRs in the 2012 Swiss DRG system. They should be the focus of attention, as the PARRs represent an avoidable loss in reimbursement.

Analyse de la prise en charge médicale et de l'impact économique des patients ayant présentés des coûts extrêmes dans un hôpital universitaire [Analysis of the medical management and the economic impact of patients who have represented extreme costs at a university hospital]

Les coûts de traitement de certains patients s'avèrent extrêmement élevés, et peuvent faire soupçonner une prise en charge médicale inadéquate. Comme I'évolution du remboursement des prestations hospitalières passe à des forfaits par pathologie, il est essentiel de vérifier ce point, d'essayer de déterminer si ce type de patients peut être identifié à leur admission, et de s'assurer que leur devenir soit acceptable. Pour les années 1995 et 1997. les coûts de traitement dépassant de 6 déviations standard le coût moyen de la catégorie diagnostique APDRG ont été identifiés, et les dossiers des 50 patients dont les coûts variables étaient les plus élevés ont été analysés. Le nombre total de patients dont I'hospitalisation a entraîné des coûts extrêmes a passé de 391 en 1995 à 328 patients en 1997 (-16%). En ce qui concerne les 50 patients ayant entraîné les prises en charge les plus chères de manière absolue, les longs séjours dans de multiples services sont fréquents, mais 90% des patients sont sortis de l'hôpital en vie, et près de la moitié directement à domicile. Ils présentaient une variabilité importante de diagnostics et d'interventions, mais pas d'évidence de prise en charge inadéquate. En conclusion, les patients qualifiés de cas extrêmes sur un plan économique, ne le sont pas sur un plan strictement médical, et leur devenir est bon. Face à la pression qu'exercera le passage à un mode de financement par pathologie, les hôpitaux doivent mettre au point un système de revue interne de I'adéquation des prestations fournies basées sur des caractéristiques cliniques, s'ils veulent garantir des soins de qualité. et identifier les éventuelles prestations sous-optimales qu'ils pourraient être amenés à délivrer. [Auteurs] Treatment costs for some patients are extremely high and might let think that medical care could have been inadequate. As hospital financing systems move towards reimbursement by diagnostic groups, it is essential to assess whether inadequate care is provided, to try to identify these patients upon admission, and make sure that their outcome is good. For the years 1995 and 1997, treatment costs exceeding by 6 standard deviations the average cost of their APDRG category were identified, and the charts of the 50 patients with the highest variable costs were analyzed. The total number of patients with such extreme costs diminished from 391 in 1995 to 328 in 1997 (-16%). For the 50 most expensive patients, long stays in several services were frequent, but 90% of these patients left the hospital alive, and about half directly to their home. They presented an important variation in diagnoses and operations, but no evidence for inadequate care. Thus, patients qualified as extreme from an economic perspective cannot be qualified as such from a medical perspective, and their outcome is good. To face the pressure linked with the change in financing system, hospitals must develop an internal review system for assessing the adequacy of care, based on clinical characteristics, if they want to guarantee good quality of care and identify potentially inadequate practice.

Evolution des transferts interhospitaliers au départ d'un centre hospitalier universitaire suisse [Trends in interhospital transfers from a Swiss university hospital center].

OBJECTIVE: Research on interhospital transfers provides a basis for describing and quantifying patient flow and its evolution over time, offering an insight into hospital organization and management and hospital overcrowding. The purpose of this study was to conduct a qualitative and quantitative analysis of patient flow and to examine trends over an eight-year period. METHODS: A retrospective descriptive study of interhospital transfers was conducted between 2003 and 2011 based on an analysis of demographic, medical and operational characteristics. Ambulance transfers and transfers requiring physician assistance were analyzed separately. RESULTS: The number of interhospital transfers increased significantly over the study period,from 4,026 in 2003 to 6,481 in 2011 (+60.9%). The number of ambulance transfers increased by almost 300% (616 in 2003 compared to 2,460 in 2011). Most of the transfers (98%) were to hospitals located less than 75 km from the university hospital (median: 24 km, 5-44). In 2011, 24% of all transfers were to psychiatric institutions. 26% of all transfer cases were direct transfers from the emergency department. An increasing number of transfers required physician assistance. 18% of these patients required ventilatory support, whole 9.8% required vasoactive drugs. 11.6% of these transfers were due to hospital overcrowding. Conclusion: The study shows that there has been a significant increase in interhospital transfers. This increase is related to hospital overcrowding and to the network-based systems governing patient care strategies.