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.

Impact of a pain protocol including hypnosis in major burns.

BACKGROUND: Pain is a major issue after burns even when large doses of opioids are prescribed. The study focused on the impact of a pain protocol using hypnosis on pain intensity, anxiety, clinical course, and costs. METHODS: All patients admitted to the ICU, aged >18 years, with an ICU stay >24h, accepting to try hypnosis, and treated according to standardized pain protocol were included. Pain was scaled on the Visual Analog Scale (VAS) (mean of daily multiple recordings), and basal and procedural opioid doses were recorded. Clinical outcome and economical data were retrieved from hospital charts and information system, respectively. Treated patients were matched with controls for sex, age, and the burned surface area. FINDINGS: Forty patients were admitted from 2006 to 2007: 17 met exclusion criteria, leaving 23 patients, who were matched with 23 historical controls. Altogether patients were 36+/-14 years old and burned 27+/-15%BSA. The first hypnosis session was performed after a median of 9 days. The protocol resulted in the early delivery of higher opioid doses/24h (p<0.0001) followed by a later reduction with lower pain scores (p<0.0001), less procedural related anxiety, less procedures under anaesthesia, reduced total grafting requirements (p=0.014), and lower hospital costs per patient. CONCLUSION: A pain protocol including hypnosis reduced pain intensity, improved opioid efficiency, reduced anxiety, improved wound outcome while reducing costs. The protocol guided use of opioids improved patient care without side effects, while hypnosis had significant psychological benefits.

Report of the Review Group on the National Children's Hospital

The Review Group, led by Chairman Dr Frank Dolphin was appointed in March 2012 to advise the Minister for Health on the options for a new childrenâ?Ts hospital, following the refusal by An Bord Pleanála to give planning permission for the proposed National Childrenâ?Ts Hospital at a site on Eccles Street. Read the Report (PDF, 4MB) Read the Appendices Document (PDF, 11MB)

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.

Standardization of in-house polymerase chain reaction for the identification of Mycobacterium tuberculosis at the reference tropical disease hospital in the State of Goiás, Brazil

This study compares smear, growth in Lowenstein-Jensen medium, and in-house polymerase chain reaction (PCR) techniques for the detection of Mycobacterium tuberculosis. A total of 72 specimens from 72 patients with clinical symptoms of tuberculosis, including 70 sputum and two bronchial aspirate samples, were tested in parallel by smear, culture, and in-house PCR techniques. From these, 48 (66.6%) were negative by the 3 methods, 2 (2.8%) were smear positive and negative by culture and in-house PCR, 11 (15.3%) were both smear and culture negative, and in-house PCR positive, 7 (9.7%) were positive by the 3 methods, 2 (2.8%) were positive by smear and culture, and negative by PCR, 2 (2.8%) were positive by culture and PCR, but smear negative. After the resolution of discrepancies in PCR results, the sensitivity and specificity for in-house PCR technique to M. tuberculosis relative to the culture, were 81.8% and 81.9%, respectively. These results confirm that this method, in-house PCR, may be a sensitive and specific technique for M. tuberculosis detection, occurring in both positive and negative smear and negative cultures.

Antimicrobial resistance of Enterococcus sp. isolated from the intestinal tract of patients from a university hospital in Brazil

This study reports the results about antimicrobial resistance of Enterococcus spp. isolated from intestinal tract of patients from a university hospital in Brazil. The identification of strains at species level was performed by conventional biochemical tests, API 20 Strep (bioMérieux), and polymerase chain reaction assay. The specie distribution was E. faecium (34%), followed by E. faecalis (33%), E. gallinarum (23.7%), E. casseliflavus (5.2%), E. avium (1%), and E. hirae (1%). Intrinsic resistance to vancomycin characterized by presence of vanC genes was found in E. gallinarum and E. casseliflavus. The high prevalence of VanC phenotype enterococci is very important because these species have been reported as causing a wide variety of infections. Vancomycin-resistant E. faecium or E. faecalis were not found and no one isolate of these species was a beta-lactamase producer. Thirteen clinical isolates of enterococci (13.4%) showed multiresistance patterns, which were defined by resistance to three classes of antibiotics plus resistance to at least one aminoglycoside (gentamicin and/or streptomycin). The resistance to several antimicrobials shown by enterococcal strains obtained in this study is of concern because of the decrease in the therapeutic options for treatment of infections caused by enterococci.

Coping and anxiety: an examination of different drinking patterns in an Irish population.

The primary aim of this study was to investigate the effect of different drinking patterns in an Irish population on ability to cope with stress. Coping ability comprised approach coping responses, avoidance coping responses and trait anxiety levels. Coping responses were measured by the coping responses inventory (CRI, Moos, 1993) and trait anxiety by the state-trait anxiety inventory (STAI, Spielberger, 1983). A total of 128 participants took part in the study and were recruited from alcohol treatment centres and the general population.This resource was contributed by The National Documentation Centre on Drug Use.

Dual diagnosis in mental health inpatient and day hospital settings.

Many mental health patients also have substance misuse problems, so mental health service staff need to be skilled to provide simple prevention and treatment interventions, assisted by drug and alcohol specialists. This guidance covers the assessment and clinical management of patients with mental illness being cared for in psychiatric inpatient or day care settings who also use or misuse alcohol and/or illicit or other drugs*. It also covers organisational and management issues to help mental health services manage these patients effectively. The key message is that the assessment and management of drug and alcohol use are core competences required by clinical staff in mental health services. The guidance aims to: â?¢ encourage integration of drug and alcohol expertise and related training into mental health service provision; â?¢ provide ideas and guidance to front-line staff and manages to help them provide the most effective therapeutic environments; â?¢ help mental health services plan action on dual diagnosisâ? .This resource was contributed by The National Documentation Centre on Drug Use.

Guidelines for the management of depression and anxiety disorders in primary care.

High risk groups for depression and anxiety disorders include those with co-occuring alcohol or other drug misuse.This resource was contributed by The National Documentation Centre on Drug Use.

Estudi del desplegament de xarxes sense fil en l'àmbit d'un hospital universitari multicèntric i d'alta complexitat

Determinar el procedimiento que se deberá llevar a cabo para realizar las medidas de campo del alcance y, en caso de que se den las circunstancias, llevar a cabo la medición de la interacción con el resto del equipamiento médico de determinadas zonas críticas.

Contact tracing investigation after professional exposure to tuberculosis in a Swiss hospital using both tuberculin skin test and IGRA.

SETTING: A 950 bed teaching hospital in Switzerland. AIM: To describe the result of a contact investigation among health care workers (HCW) and patients after exposure to a physician with smear-positive pulmonary tuberculosis in a hospital setting using standard tuberculin skin tests (TST) and Interferon-gamma release assay (IGRA). METHOD: HCW with a negative or unknown TST at hiring had a TST two weeks after the last contact with the index case (T0), repeated six weeks later if negative (T6). All exposed HCW had a T-SPOT.TB at T0 and T6. Exposed patients had a TST six weeks after the last contact, and a T-SPOT.TB if the TST was positive. RESULTS: Among 101 HCW, 17/73 (22%) had a positive TST at T0. TST was repeated in 50 at T6 and converted from negative to positive in eight (16%). Twelve HCW had a positive T-SPOT.TB at T0 and ten converted from negative to positive at T6. Seven HCW with a positive T-SPOT.TB reverted to negative at T6 or at later controls, most of them with test values close to the cut-off. Among 27 exposed patients tested at six weeks, ten had a positive TST, five of them confirmed by a positive T-SPOT.TB. CONCLUSIONS: HCW tested twice after exposure to a case of smear-positive pulmonary TB demonstrated a possible conversion in 10% with T-SPOT and 16% with TST. Some T-SPOT.TB reverted from positive to negative during the follow-up, mostly tests with a value close to the cut-off. Due to the variability of the test results, it seems advisable to repeat the test with values close to the cut-off before diagnosing the presence of a tuberculous infection.

Hospital admission rates for alcoholic intoxication after policy changes in the canton of Geneva, Switzerland.

Background: In February, 2005, the canton of Geneva in Switzerland prohibited the off-premise sale of alcoholic beverages between 9pm and 7am, and banned their sale in gas stations and video stores. The aim of this study is to assess the impact of this policy change on hospital admission rates for alcoholic intoxication.Methods: An interrupted time series analysis of this natural experiment was performed with data on hospitalisations for acute alcoholic intoxication during the 2002-2007 period. The canton of Geneva was treated as the experimental group, while all other Swiss cantons were used as the control group.Results: In the experimental site, the policy change was found to have a significant effect on admission rates among adolescents and young adults. Depending on the age group, hospitalisation rates for alcoholic intoxication fell by an estimated 25-40% as the result of restricted alcohol availability.Conclusions: Modest restrictions on opening hours and the density of off-premise outlets were found to be of relevance for public health in the canton of Geneva. In light of this finding, policy makers should consider such action as a promising approach to alcohol prevention. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

Susceptibility of clinical isolates of multiresistant Pseudomonas aeruginosa to a hospital disinfectant and molecular typing

The aim of this study was to evaluate the susceptibility of 35 resistant Pseudomonas aeruginosa clinical isolates to a quaternary ammonium hospital disinfectant. The methodology was the AOAC Use-Dilution Test, with disinfectant at its use-concentration. In addition, the chromosomal DNA profile of the isolates were determined by macro-restriction pulsed field gel electrophoresis (PFGE) method aiming to verify the relatedness among them and the behavior of isolates from the same group regarding the susceptibility to the disinfectant. Seventy one percent of the isolates were multiresistant to antibiotics and 43% showed a reduced susceptibility to the disinfectant. The PFGE methodology detected 18 major clonal groups. We found isolates with reduced susceptibility to the disinfectant and we think that these are worrying data that should be further investigated including different organisms and chemical agents in order to demonstrate that microorganisms can be destroyed by biocide as necessary. We also found strains of the same clonal groups showing different susceptibility to the disinfectant. This is an interesting observation considering that only few works are available about this subject. PFGE profile seems not to be a reliable marker for resistance to disinfectants.

Gestor d'un hospital

La finalitat d'aquest projecte és realitzar el desenvolupament d'una aplicació fent servir la tecnologia .NET, que és una tecnologia actualment en gran expansió, amb la voluntat d'explorar les seves possibilitats. En concret, hem fet servir ASP.NET, C# i la seva connectivitat amb SQL-Server mitjançant ADO.NET.

The health status of children without a resident permit consulting the Children's Hospital of Lausanne

Rapport de synthèseObjectif: Evaluer les données sociales, économiques et médicales concernant les enfants sans permis de séjour pris en charge à l'Hôpital de l'Enfance afin de pouvoir mieux comprendre leurs besoins spécifiques.Conclusions: La majorité des enfants ayant participé à l'étude sont originaires d'Amérique Latine et vivent dans des conditions de vie très précaires. Leur état de santé global est satisfaisant et la plupart bénéficient d'un suivi médical régulier. La prévention ciblée sur une meilleure hygiène de vie est particulièrement importante en raison de l'incidence élevée de sur poids et d'obésité dans cette population. Ce qui est connu et ce que l'étude apporte de nouveau: Cette étude est la 1ère qui analyse la situation socio-économique et l'état de santé d'enfants sans?papiers en Suisse. Les points forts de cette étude sont son caractère prospectif et le suivi de plus de la moitié de ces enfants à 1 an malgré une population particulièrement vulnérable et difficile à monitorer.Méthode: Etude exploratoire prospective par le biais d'un questionnaire incluant des données socio-démographiques, médicales et scolaires de 103 enfants sans permis de séjour ayant consulté pour la 1ère fois l'Hôpital de l'Enfance entre août 2003 et mars 2006. Ces enfants étaient ensuite reconvoqués pour une deuxième consultation 1 année plus tard afin d'obtenir un suivi médical.Résultats principaux: 87% des enfants sont originaires d'Amérique Latine, 36% ont moins de 2 ans. Cette population vit dans des conditions précaires avec un revenu familial sous le seuil de pauvreté (89% des familles vivent avec moins de 3100.- CHF/mois). Les raisons principales de consultation étaient des maladies infectieuses, un bilan de santé demandé par l'école ou un contrôle du nourrisson. La plupart des enfants étaient en bonne santé ou présentaient les mêmes pathologies retrouvées chez des enfants d'un âge similaire. 13% des enfants entre 2 et 16 ans sont obèses et 27% souffrent de surpoids. Tous les enfants en âge d'être scolarisés fréquentent l'école dans l'année suivant le 1er contrôle médical et 48% sont assurés auprès d'une assurance maladie.Biais: Au contrôle medical à 1 an, nous n'avions pas de donnée supplémentaire concernant 43% des enfants qui avaient été perdus de vue (courrier envoyé revenu en retour).