Faire face au COVID-19, mise en place de novo d’une unité mutualisée « COVID-19 non réanimatoire » : organisation et résultats

Introduction

La pandémie à COVID-19 a touché presque tous les pays du monde, dont la France. Tous les départements français ont ouvert des unités dédiées pour la gestion de la phase aiguë de l’épidémie. Au sein de notre site, notre structure a été la seule à accueillir une unité pour gérer des patients confirmés COVID-19 positifs. En l’absence de soins intensifs sur place, ces patients étaient triés au SAU et ne venaient que les patients sans indication de soins intensifs en raison du bénéfice/risque attendu (âge, comorbidités). Pour activer cette unité, une équipe mutualisée a été mise en place que ce soit au niveau du personnel médical PM (seniors, internes, externes) que personnel non médical (PNM) détachés des services de médecine interne, pédiatrie, médecine du sport, consultation, endocrinologie, hépatologie de notre CHU. Un support psychologique a été proposé aux soignants et aux familles par une équipe mobile de psychiatrie. L’activité quotidienne a été réorganisée après la création de plusieurs binômes junior-senior, en service de 8 h à 19 h, 7 j/7. La continuité des soins a été assurée chaque jour par 3 staffs pour permettre respectivement les transmissions de la nuit entre PM et PNM ; l’état des lieux après la visite du matin ; les projets pour le lendemain. Tous les patients ont été réévalués chaque jour et réorientés selon une échelle de gravité structurée par 5 codes-couleurs. Les externes ont eu pour mission de contacter les familles du fait de la limitation des visites, ainsi que les médecins traitants afin d’améliorer la gestion après le RAD. Les patients ont été traités par oxygénothérapie et protocoles d’antibiothérapie et morphine.

Matériels et méthodes

Analyse descriptive des données personnelles, de la mortalité brute et des issues de l’hospitalisation.

Résultats

Entre le 13 mars et le 19 mai, 147 patients, 56 % d’eux de sexe féminin, ont été hospitalisés dans cette unité d’une capacité maximale de 25 lits. L’âge moyen était de 69 ans [18 ; 97]. La durée moyenne du séjour a été de 5 jours [0 : 29]. La mortalité totale était du 20,4 %, dont 51 % des patients sont rentrés vers leur domicile ou vers des EHPAD. Ensuite, 14,3 % des patients ont été transférés vers un autre service de médecine aiguë, et 12,2 % des patients a poursuit les soins dans un SSR.

Conclusion

L’organisation de ce service montre comme une équipe de PM et PNM avec fonds de travail différentes peut être rapidement mise en place pendant une période de crise. La présence d’un service dédié à la gestion des cas de COVID-19 sans indication à soins intensifs peut soulager des autres services au sein d‘un groupe hospitalier qui travaille en coordination. La mortalité des patients hospitalisés dans ce service reste baisse considérant les comorbidités et l’âge des patients. La durée courte du séjour a permis d’accueillir un grand nombre de patients et de garantir de places en médecine aiguë standard au sein du GH.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Antenatal testing for anaemia, HIV and syphilis in Indonesia - a health systems analysis of low coverage

BACKGROUND

Adverse pregnancy outcomes can be prevented through the early detection and treatment of anaemia, HIV and syphilis during the antenatal period. Rates of testing for anaemia, HIV and syphilis among women attending antenatal services in Indonesia are low, despite its mandate in national guidelines and international policy.

METHODS

Midwife-held antenatal care records for 2015 from 8 villages in 2 sub-districts within Cianjur district were reviewed, alongside the available sub-district Puskesmas (Community Health Centre) maternity and laboratory records. We conducted four focus group discussions with kaders (community health workers) (n = 16) and midwives (n = 9), and 13 semi-structured interviews with laboratory and counselling, public sector maternity and HIV management and relevant non-governmental organisation staff. Participants were recruited from village, sub-district, district and national level as relevant to role.

RESULTS

We were unable to find a single recorded result of antenatal testing for HIV, syphilis or anaemia in the village (566 women) or Puskesmas records (2816 women) for 2015. Laboratory records did not specifically identify antenatal women. Participants described conducting and reporting testing in a largely ad hoc manner; relying on referral to health facilities based on clinical suspicion or separate non-maternity voluntary counselling and testing programs. Participants recognized significant systematic challenges with key differences between the more acceptable (and reportedly more often implemented) haemoglobin testing and the less acceptable (and barely implemented) HIV and syphilis testing. However, a clear need for leadership and accountability emerged as an important factor for prioritizing antenatal testing and addressing these testing gaps.

CONCLUSIONS

Practical solutions such as revised registers, availability of point-of-care tests and capacity building of field staff will therefore need to be accompanied by both funding and political will to coordinate, prioritize and be accountable for testing in pregnancy.

Variation in esophageal anastomosis technique-the role of collaborative learning

Centralization of care has improved outcomes in esophagogastric (EG) cancer surgery. However, specialist surgical centers often work within clinical silos, with little transfer of knowledge and experience. Although variation exists in multiple dimensions of perioperative care, the differences in operative technique are rarely studied. An esophageal anastomosis workshop was held to identify areas of common and differing practice within the operative technique. Surgeons showed videos of their anastomosis technique by open and minimally invasive surgery. Each video was followed by a discussion. Surgeons from 10 different EG cancer centers attended. Eight key technical differences and learning points were identified and discussed: the optimum diameter of the gastric conduit; avoiding ischemia in the gastric conduit; minimizing esophageal trauma; the use of an esophageal mucosal collar; omental wrapping; intraoperative leak testing; ideal diameter of the circular stapler and the growing use of linear stapled anastomoses. The workshop received positive feedback from participants and on 2 years follow-up, 40% stated that they believed that the learning of tips and techniques during the workshop has contributed to lowering their anastomotic leak rate. Many differences exist in surgical technique. The reasons for, and crucially the significance of, these differences must be discussed and examined. Workshops provide a forum for peer-to-peer collaborative learning to reflect on one's own practice and improve surgical technique. These changes can, in turn, generate incremental improvements in patient care and postoperative outcomes.

P3346Validation of obesity coding among newly-treated nonvalvular atrial fibrillation patients using an integrated electronic medical record and claims database

Background

Obesity is prevalent among patients with non-valvular atrial fibrillation (NVAF). Administrative claims databases offer the opportunity to evaluate obesity and morbid obesity in this patient population. However, there is limited information about the use and accuracy of diagnosis codes in claims data to identify obesity and morbid obesity among patients with NVAF.

Purpose

To evaluate the use and accuracy of diagnosis codes in claims data for identifying obesity and morbid obesity among newly-treated NVAF patients using a large geographically-diverse US database.

Methods

This retrospective study used Optum's de-identified integrated electronic medical record (EMR) and claims database (1/1/2013–3/31/2018). Adult (≥18 years) patients with ≥1 claim for an oral anticoagulant (OAC) from 1/1/2014–9/30/2017 were identified (treatment date as index date). Patients were required to have ≥1 atrial fibrillation diagnosis prior to the index date and were excluded if they had evidence of OAC use or valvular disease during the 12 months prior to the index date. Patients were required to have ≥12 months of continuous enrollment prior to and ≥6 months after the index date as well as ≥1 BMI measurement in the EMR data during the 6 months before or after the index date. Based on the World Health Organization's definition, patients were classified as obese if their BMI was ≥30 kg/m2 and morbidly obese if their BMI was ≥40 kg/m2. Sensitivity, specificity, and positive predictive value (PPV) were calculated to assess the accuracy of diagnosis codes for obesity (ICD-9 diagnosis codes: 278.00, 278.01, 278.03, V85.30-V85.39, V85.41-V85.45; ICD-10 diagnosis codes: E66.01, E66.09, E66.2, E66.8, E66.9, Z68.30-Z68.39, Z68.41-Z68.45) and morbid obesity (ICD-9 diagnosis codes: 278.01, V85.41-V85.45; ICD-10 diagnosis codes: E66.01, E66.2, Z68.41-Z68.45) commonly used in claims database research.

Results

There were 7,501 patients included in the newly-treated NVAF cohort (mean [±SD] age=72.4 [±10.7] years, 55% male, 90% white, and mean [±SD] Quan-Charlson Comorbidity Index =2.10 [±2.08]). Forty-six percent of these patients had BMI≥30 kg/m2, of whom about one-quarter (11% of the overall sample) had a BMI≥40 kg/m2. In contrast, 25% and 10% of patients had a diagnosis code for obesity or morbid obesity, respectively. For obesity diagnosis codes, sensitivity, specificity, and PPV were 49% (95% CI: 47%-50%), 95% (95%-96%), and 90% (88%-91%), respectively. For morbid obesity diagnosis codes, sensitivity, specificity, and PPV were 63% (59%-63%), 96% (96%-97%) and 68% (64%-71%), respectively.

Conclusion

Among newly-treated NVAF patients, obesity diagnosis codes in the claims database had high PPV, high specificity, and modest sensitivity. Morbid obesity diagnosis codes also had high specificity but modest PPV and sensitivity. These findings have implications for both case selection and control for obesity as a confounder in observational studies using a claims database.

Acknowledgement/Funding

The funding for the research project was provided by Pfizer Inc.

Evidence-Based Guideline on Laparoscopy in Pregnancy: Commissioned by the British Society for Gynaecological Endoscopy (BSGE) Endorsed by the Royal College of Obstetricians & Gynaecologists (RCOG)

Laparoscopy is widely utilised to diagnose and treat acute and chronic, gynaecological and general surgical conditions. It has only been in recent years that laparoscopy has become an acceptable surgical alternative to open surgery in pregnancy. To date there is little clinical guidance pertaining to laparoscopic surgery in pregnancy. This is why the BSGE commissioned this guideline. MEDLINE, EMBASE, CINAHL and the Cochrane library were searched up to February 2017 and evidence was collated and graded following the NICE-approved process. The conditions included in this guideline are laparoscopic management of acute appendicitis, acute gall bladder disease and symptomatic benign adnexal tumours in pregnancy. The intended audience for this guideline is obstetricians and gynaecologists in secondary and tertiary care, general surgeons and anaesthetists. However, only laparoscopists who have adequate laparoscopic skills and who perform complex laparoscopic surgery regularly should undertake laparoscopy in pregnant women, since much of the evidence stems from specialised centres.

Evaluating societal outcomes of orthognathic surgery: an innovative application of the Social Return on Investment methodology to patients after orthognathic treatment

Outcomes after orthognathic treatment are complex, and include improvements to mental and physical health, and psychosocial adjustments. The Social Return on Investment (SROI), a framework that is recognised by the government, explores the wider social value of interventions, but has not yet, to our knowledge, been used to measure the value of surgical procedures. To test its feasibility in a surgical setting and to begin to understand the wider nature of the changes experienced by patients after orthognathic surgery, we designed a pilot study that focused on the first two stages of the six-stage model. We collected data from 16 participants about their perceptions and experiences of the short, medium, and longer term outcomes of their treatment during two qualitative storyboard workshops. A grounded theory-SROI method was used to explore their experiences through a process of constant comparison by which data were analysed for concepts and organised into distinct themes. This produced a theory of change that clearly expressed the short to medium-term and longer term outcomes of orthognathic treatment, and provided an initial framework for the approach. The theory captured several outcomes and showed that the framework can be used effectively to investigate the wider psychosocial changes after orthognathic treatment. It therefore provides a basis on which to develop potential indicators for the assessment and valuation of these outcomes over time. The application of these findings to the selection of patients, engagement, and postoperative care, is briefly discussed.

Human echolocators adjust loudness and number of clicks for detection of reflectors at various azimuth angles

In bats it has been shown that they adjust their emissions to situational demands. Here we report similar findings for human echolocation. We asked eight blind expert echolocators to detect reflectors positioned at various azimuth angles. The same 17.5 cm diameter circular reflector placed at 100 cm distance at 0°, 45° or 90° with respect to straight ahead was detected with 100% accuracy, but performance dropped to approximately 80% when it was placed at 135° (i.e. somewhat behind) and to chance levels (50%) when placed at 180° (i.e. right behind). This can be explained based on poorer target ensonification owing to the beam pattern of human mouth clicks. Importantly, analyses of sound recordings show that echolocators increased loudness and numbers of clicks for reflectors at farther angles. Echolocators were able to reliably detect reflectors when level differences between echo and emission were as low as -27 dB, which is much lower than expected based on previous work. Increasing intensity and numbers of clicks improves signal-to-noise ratio and in this way compensates for weaker target reflections. Our results are, to our knowledge, the first to show that human echolocation experts adjust their emissions to improve sensory sampling. An implication from our findings is that human echolocators accumulate information from multiple samples.