Optimisation des prescriptions en réanimation

[Rationalization of biological tests in cardiology department]

INTRODUCTION

Laboratory tests usually complete clinical examinations for diagnostic, prognostic and even therapeutical care. However, French doctors might too easily prescribe such examinations without knowing their cost. As a matter of fact, the prescription is sometimes excessive or unjustified. Cardiology is not an exception, with costly laboratory tests.

OBJECTIVE

To show that the relevance of each additional test prescription, in a cardiology department, allows a significant reduction of the examination volumes and costs, with no prejudicial effect on patients' care.

METHODS

Two consecutive 2-year periods, between November 1st 2011 and October 31st 2015, - before and after the development of a policy of rationalization of additional tests - were compared. All the patients admitted in our cardiology department during these periods were prospectively included.During 4 years, the volume and the cost of prescription of the most frequent laboratory tests were studied, considering successive half-year periods.

RESULTS

After rationalizing, there was a significant reduction of prescription of the laboratory tests (CBC -72%, BNP -92%, troponin -82%, CRP -89%, liver test -87%, lipid status -80%, TSH -80%, p<0.01).No serious adverse events were reported and no death rate increase was noticed.

CONCLUSION

Rationalizing allows a significant reduction of complementary examinations, with no additional risk for the patient.

[Cost awareness at emergencies: multicentric survey among prescribers]

AIM

Regular increasing of health-care expense brought about the development of medical implication in prescription control and the will to give more responsibility to prescribers. Emergency departments account for a large part of hospital expenses. This study was carried out to evaluate cost awareness among French emergency physicians.

METHODS

A questionnaire was sent to 160 physicians (junior and senior grade) working at the emergency department of 12 hospitals in the Lyon region (France). Every participant had to estimate the true hospital costs of a selection of drugs, blood products, laboratory tests and imaging modalities.

RESULTS

One hundred and seven questionnaires (68%) were returned and analysed: 48 filled in by juniors (45%), 59 by seniors (55%). Only 26 physicians accurately estimated costs within 50% of the true cost. Response errors were underestimations averaging 4695±226euros, i.e. -59±3% of the total sum (7899euros). Drug prescriptions were significantly (P<0.001) the most underestimated (-74±3%), when compared to both imaging modalities (-23±5%) or blood products prescriptions (-37±6%). High-cost drugs (>1000euros) were the most overestimated pharmaceuticals (-82±2%). Laboratory tests were rather overestimated (+12±8%). Junior grade physicians underestimated more costs than senior physicians (P=0.04).

DISCUSSION

Physicians had a poor understanding of prescription costs at the emergencies, especially regarding high-cost drugs. Much progress is required to integrate the cost-containment problem in daily prescriptions at the emergency department.

[Drug's administration via feeding tubes: evaluation of practices in an intensive care unit of a Tunisian hospital]

INTRODUCTION

Drugs' administration via feeding tubes is a potential source of iatrogenic events for the intensive care patients because of the problem of not adapted galenic forms.

OBJECTIVES

We analyzed the prescriptions of patients with enteral feedings to determine if the galenic forms were compatible with administration via feeding tubes. We also observed and analyzed the methods of drugs passage by nurses.

PATIENTS AND METHODS

We analyzed 30 prescriptions of patients with enteral feedings in the intensive care unit of Habib Bourguiba Sfax hospital, by a prospective and exhaustive way. We also, observed and evaluated the practices of preparation and administration of drugs to these patients via feeding tube by nurses.

RESULTS

Only 12% of drugs were liquids. Eighty-eight percent of the drugs were pulverised and capsule open before administration. The galenic form was not in conformity for 20% of drugs because of the prohibition to crushing tablet or opening capsule (gastroresistant form was dissolved), or because of the administration of a parenteral form (risk of irritation). Among 78 drugs administered by 10 different nurses, the time between passage of the drug and enteral nutrition were not respected for 59% of the observations. The drugs were managed in mixture for 90% of the observations. The gloves were not worn in 80% of observations. No rinsing is made between consecutive administrations and before administration.

CONCLUSION

This study shows that it is possible to reduce risk of administration errors in the intensive care unit and to facilitate the administration of drug via feeding tube by prescribing liquid oral form or soluble solid oral form. It also shows the need for cooperation with the pharmacist in order to adapt the galenic forms and to redact protocol of administration.