Oligoanalgesia in the emergency department: short-term beneficial effects of an education program on acute pain.

STUDY OBJECTIVE: Acute pain is the most frequent complaint in emergency department (ED) admissions, but its management is often neglected, placing patients at risk of oligoanalgesia. We evaluate the effect of the implementation of guidelines for pain management in ED patients with pain at admission or anytime during their stay in our ED. METHODS: This prospective pre-post intervention cohort study included data collection both before and after guideline implementation. Consecutive adult patients admitted with acute pain from any cause or with pain at any time after admission were enrolled. The quality of pain management was evaluated according to information in the ED medical records by using a standardized collection form, and its impact on patients was recorded with a questionnaire at discharge. RESULTS: Two hundred forty-nine and 192 patients were included during pre- and postintervention periods. Pain was documented in 61% and 76% of nurse and physician notes, respectively, versus 78% and 85% after the intervention (difference 17%/9%; 95% confidence interval [CI] 8% to 26%/2% to 17%, respectively). Administration of analgesia increased from 40% to 63% (difference 23%; 95% CI 13% to 32%) and of morphine from 10% to 27% (difference 17%; 95% CI 10% to 24%). Mean doses of intravenous morphine increased from 2.4 mg (95% CI 1.9 to 2.9 mg) to 4.6 mg (95% CI 3.9 to 5.3 mg); administration of nonsteroidal antiinflammatory drugs and acetaminophen increased as well. There was a greater reduction of visual analogue scale score after intervention: 2.1 cm (95% CI 1.7 to 2.4 cm) versus 2.9 cm (95% CI 2.5 to 3.3 cm), which was associated with improved patient satisfaction. CONCLUSION: Education program and guidelines implementation for pain management lead to improved pain management, analgesia, and patient satisfaction in the ED.

Mise en place d'un programme de prévention et de prise en charge du diabète en Suisse: le point de vue des patients et des professionnels de la santé [Implementation of a diabetes disease management program in Switzerland: patients' and healthcare professionals' point of view].

BACKGROUND: A reorganization of healthcare systems is required to meet the challenge of the increasing prevalence of chronic diseases, e.g. diabetes. In North-America and Europe, several countries have thus developed national or regional chronic disease management programs. In Switzerland, such initiatives have only emerged recently. In 2010, the canton of Vaud set up the "Diabetes Cantonal Program", within the framework of which we conducted a study designed to ascertain the opinions of both diabetic patients and healthcare professionals on the elements that could be integrated into this program, the barriers and facilitators to its development, and the incentives that could motivate these actors to participate. METHODS: We organized eight focus-groups: one with diabetic patients and one with healthcare professionals in the four sanitary areas of the canton of Vaud. The discussions were recorded, transcribed and submitted to a thematic content analysis. RESULTS: Patients and healthcare professionals were rather in favour of the implementation of a cantonal program, although patients were more cautious concerning its necessity. All participants envisioned a set of elements that could be integrated to this program. They also considered that the program could be developed more easily if it were adapted to patients' and professionals' needs and if it used existing structures and professionals. The difficulty to motivate both patients and professionals to participate was mentioned as a barrier to the development of this program however. Quality or financial incentives could therefore be created to overcome this potential problem. CONCLUSION: The identification of the elements to consider, barriers, facilitators and incentives to participate to a chronic disease management program, obtained by exploring the opinions of patients and healthcare professionals, should favour its further development and implementation.

Mammographic screening for breast cancer: background of a pilot program in the Canton of Vaud.

For several years now, substantial efforts have been devoted to the development and the implementation of a screening program for breast cancer in the Canton of Vaud. A four-year pilot phase is now starting, involving two regional hospitals with their catchment areas; women over 50 and under 70 years old will be invited to participate in the program. A double view mammography will be made, with a double reading made by the hospital radiologists; a third reading will be made in case of discrepancy between the two first radiologists. Patients classified as positive for screening (e.g., with a suspect radiological image) will be referred to their practitioner for further diagnosis and treatment. The medical and public health background of this program is discussed, more specifically the reasons for developing a screening program, the choice of mammography rather than other tools, and the need to implement screening as an organized program.

Treatment and Early Intervention in Psychosis Program (TIPP-Lausanne): implementation of an early intervention programme for psychosis in Switzerland.

AIM: In a survey conducted in the Lausanne catchment area in 2000, we could estimate on the basis of file assessment that first-episode psychosis (FEP) patients had psychotic symptoms for more than 2 years before treatment and that 50% did not attend any outpatient appointment after discharge from hospital. In this paper, we describe the implementation of a specialized programme aimed at improving engagement and quality of treatment for early psychosis patients in the Lausanne catchment area in Switzerland. METHOD: The Treatment and Early Intervention in Psychosis Program-Lausanne is a comprehensive 3-year programme composed of (i) an outpatient clinic based on assertive case management; (ii) a specialized inpatient unit; and (iii) an intensive mobile team, connected for research to the Center for Psychiatric Neuroscience. RESULTS: Eight years after implementation, the programme has included 350 patients with a disengagement rate of 9% over 3 years of treatment. All patients have been assessed prospectively and 90 participated in neurobiological research. Based on this experience, the Health Department funded the implementation of similar programmes in other parts of the state, covering a total population of 540 000 people. CONCLUSION: Programmes for early intervention in psychosis have a major impact on patients' engagement into treatment. While development of mobile teams and assertive case management with specific training are crucial, they do not necessitate massive financial support to be started. Inclusion of a research component is important as well, in terms of service planning and improvement of both quality of care and impact of early intervention strategies.

Dépistage néonatal systématique de la mucoviscidose en Suisse: dès janvier 2011 [Implementation of the neonatal cystic fibrosis screening program in Switzerland: beginning January 2011].

The diagnosis of cystic fibrosis (CF) is often delayed because of the nonspecificity of a wide variety of clinical symptoms at disease onset. Newborn screening for CF has been advocated to reduce delays in diagnosis, facilitating preventive care for early respiratory and nutritional involvement. According to American and European consensus and experience of existing programs, a Swiss Nationwide Cystic Fibrosis Newborn Screening Program started in January 2011. Screening strategy combines two steps: an immunoreactive trypsinogen assay and DNA mutation analysis in dried blood samples at day 4 (Guthrie cards).

How can we teach EBM in clinical practice? : an analysis of barriers to implementation of on-the-job EBM teaching and learning.

Introduction: Evidence-based medicine (EBM) improves the quality of health care. Courses on how to teach EBM in practice are available, but knowledge does not automatically imply its application in teaching. We aimed to identify and compare barriers and facilitators for teaching EBM in clinical practice in various European countries. Methods: A questionnaire was constructed listing potential barriers and facilitators for EBM teaching in clinical practice. Answers were reported on a 7-point Likert scale ranging from not at all being a barrier to being an insurmountable barrier. Results: The questionnaire was completed by 120 clinical EBM teachers from 11 countries. Lack of time was the strongest barrier for teaching EBM in practice (median 5). Moderate barriers were the lack of requirements for EBM skills and a pyramid hierarchy in health care management structure (median 4). In Germany, Hungary and Poland, reading and understanding articles in English was a higher barrier than in the other countries. Conclusion: Incorporation of teaching EBM in practice faces several barriers to implementation. Teaching EBM in clinical settings is most successful where EBM principles are culturally embedded and form part and parcel of everyday clinical decisions and medical practice.

Time for change: a roadmap to guide the implementation of the World Anti-Doping Code 2015

A medical and scientific multidisciplinary consensus meeting was held from 29 to 30 November 2013 on Anti-Doping in Sport at the Home of FIFA in Zurich, Switzerland, to create a roadmap for the implementation of the 2015 World Anti-Doping Code. The consensus statement and accompanying papers set out the priorities for the antidoping community in research, science and medicine. The participants achieved consensus on a strategy for the implementation of the 2015 World Anti-Doping Code. Key components of this strategy include: (1) sport-specific risk assessment, (2) prevalence measurement, (3) sport-specific test distribution plans, (4) storage and reanalysis, (5) analytical challenges, (6) forensic intelligence, (7) psychological approach to optimise the most deterrent effect, (8) the Athlete Biological Passport (ABP) and confounding factors, (9) data management system (Anti-Doping Administration & Management System (ADAMS), (10) education, (11) research needs and necessary advances, (12) inadvertent doping and (13) management and ethics: biological data. True implementation of the 2015 World Anti-Doping Code will depend largely on the ability to align thinking around these core concepts and strategies. FIFA, jointly with all other engaged International Federations of sports (Ifs), the International Olympic Committee (IOC) and World Anti-Doping Agency (WADA), are ideally placed to lead transformational change with the unwavering support of the wider antidoping community. The outcome of the consensus meeting was the creation of the ad hoc Working Group charged with the responsibility of moving this agenda forward.

La dépression majeure en hôpital général: adaptation et mise en oeuvre de recommandations pour la pratique clinique [Major depression in the general hospital: adaptation and implementation of guidelines]

Major depression IMD) is highly prevalent in the general hospital and adds a considerable burden to affected patients, but remains under detected and under treated. In an attempt to improve this situation, existing guidelines on MD were retrieved, systematically evaluated with the instrument AGREE (Appraisal of guidelines for research and evaluation), and adapted to the needs of the general hospital. These guidelines were made available on intranet, and actively implemented in two wards, where their impact on clinical practice was evaluated.

Implementation of robotic laparoscopic cholecystectomy in a university hospital.

BACKGROUND: Robot surgery is a further step towards new potential developments in minimally invasive surgery. Surgeons must keep abreast of these new technologies and learn their limits and possibilities. Robot-assisted laparoscopic cholecystectomy has not yet been performed in our institution. The purpose of this report is to present the pathway of implementation of robotic laparoscopic cholecystectomy in a university hospital. METHODS: The Zeus(R) robot system was used. Experimental training was performed on animals. The results of our experimental training allowed us to perform our first two clinical cases. RESULTS: Robot arm set-up and trocar placement required 53 and 35 minutes. Operative time were 59 and 45 minutes respectively. The overall operative time was 112 and 80 minutes, respectively. There were no intraoperative complications. Patients were discharged from the hospital after an overnight stay. CONCLUSION: Robotic laparoscopic cholecystectomy is safe and patient recovery similar to those of standard laparoscopy. At present, there are no advantages of robotic over conventional surgery. Nevertheless, robots have the potential to revolutionise the way surgery is performed. Robot surgery is not reserved for a happy few. This technology deserves more attention because it has the potential to change the way surgery is performed.