Impact of the presence of a mediator on patient violent or uncivil behaviours in emergency departments: a cluster randomised crossover trial

BACKGROUND AND IMPORTANCE

Several studies reported that violent behaviours were committed by patients against healthcare professionals in emergency departments (EDs). The presence of mediators could prevent or resolve situations of tension.

OBJECTIVE

To evaluate whether the presence of mediators in EDs would have an impact on violent behaviours committed by patients or their relatives against healthcare professionals. Design, settings and participants A 6-period cluster randomised crossover trial was performed in 4 EDs during 12 months. Patients aged ≥18 and their relatives were included.

INTERVENTION

In order to prevent or resolve situations of tension and conflict, four mediators were recruited.Outcome measure and analysis Using a logistic regression mixed model, the rate of ED visits in which at least one act of violence was committed by a patient or their relatives, reported by healthcare professionals, was compared between the intervention group and the control group.

RESULTS

A total of 50 429 ED visits were performed in the mediator intervention group and 50 851 in the control group. The mediators reported 1365 interventions; >50% of the interventions were to answer questions about clinical management or waiting time. In the intervention group, 173 acts of violence were committed during 129 ED visits, and there were 145 acts of violence committed during 106 ED visits in the control group. The rate of ED visits in which at least one act of violence was committed, was 0.26% in the intervention group and 0.21% in the control group (OR = 1.23; 95% CI [0.73-2.09]); on a 4-level seriousness scale, 41.6% of the acts of violence were rated level-1 (acts of incivility or rudeness) in the intervention group and 40.0% in the control group.

CONCLUSION

The presence of mediators in the ED was not associated with a reduction in violent or uncivil behaviours committed by patients or their relatives. However, the study highlighted that patients had a major need for information regarding their care; improving communication between patients and healthcare professionals might reduce the violence in EDs.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT03139110).

A Participatory Approach Involving Patients with Cystic Fibrosis and Healthcare Professionals for the Co-Design of an Adherence-Enhancing Intervention Toolkit

Purpose

Cystic fibrosis (CF) is an inherited life-shortening disease involving a significant treatment burden. Few interventions have been proven effective in improving adherence, and of these fewer have been adopted for implementation. Patient participation in research is increasingly desired in developing relevant health care services. A participatory approach was implemented in an adult CF center to co-design an adherence-enhancing intervention toolkit. We aimed to report on the participatory process and the results regarding the co-designed intervention.

Patients and Methods

Two focus group sessions and four working sessions were conducted at 4-week intervals with three healthcare professionals (HCP; physician, nurse, physiotherapist), eight patients, and two researchers (sociologist, public health pharmacist). The two initial focus group sessions were dedicated to the collection of narratives about CF treatment experiences to identify drivers of adherence. The next four working sessions were dedicated to the reflection on solutions that could alleviate the difficulties identified and be used in current clinical practice. The researchers observed during all sessions the interactions between participants, group dynamics, and process of implementation of the collective reflection.

Results

The process facilitated an active participation of patients and HCP, who contributed equally to the intervention development. The co-design adherence-enhancing intervention toolkit consisted in a self-questionnaire to be completed by patients before the medical consultation and used as a communication support during the consultation, plus a toolkit of solutions to be proposed by the HCP for each barrier identified by patients, and to be followed up during the next consultation.

Conclusion

This study demonstrated that a participatory approach involving CF patients and HCP lead to the development of an adherence-enhancing intervention toolkit, using a 6-session format; the benefits of the co-designed intervention on the medication adherence have yet to be tested in a multicenter, open-label study in 3 centers in France.

Feelings of Trust and of Safety Are Related Facets of the Patient's Experience in Surgery: A Descriptive Qualitative Study in 80 Patients

OBJECTIVE

Few studies to date have explored the question of the safety of a hospital stay from the patient's point of view. The aim of this study was to describe patients' own perspectives on the safety of the surgical care they received. A qualitative study was conducted based on interviews.

METHODS

Semidirected interviews were conducted by a sociologist with adult patients admitted for hospitalization in 2 orthopedic and in 2 digestive surgery wards in 4 hospitals.

RESULTS

Eighty interviews were transcribed and analyzed. The patients surveyed averaged 61.7 years old (SD, 16.0 y). Forty-eight percent were men (n = 38). The issue of the safety of care, as defined by professionals, is little apprehended by patients. In their view, sense of safety was related to the trust in the surgeon, which is a requisite condition for a sense of security and is based on interactions with the surgeon and on their communication style. Sense of safety was also related to the preoperative consultation, in which the procedure is explained and illustrated and to a postoperative encounter with a person who participated in the operation.

CONCLUSIONS

Patients' sense of safety is linked to the amount of trust they have in their surgeons. New strategies to improve language practices and surgeon-patient interaction should be developed, along with organizational improvement guaranteeing that participants of the surgery debrief with the patient.The study has been registered at ClinicalTrials.gov (identifier: NCT02820545).

Safety Attitude of Operating Room Personnel Associated With Accurate Completion of a Surgical Checklist: A Cross-sectional Observational Study

OBJECTIVE

How the checklist is executed in routine practice may reflect the teamwork and safety climate in the operating room (OR). This cross-sectional study aimed to identify whether the presence of a fully completed checklist in medical records was associated with teams' safety attitudes.

METHODS

Data from 29 French hospitals, including 5677 operated patients and 834 OR professionals, were prospectively collected. The degree of checklist compliance was categorized for each patient in 1 of 4 ways: full, incomplete, inaccurate, and no checklist completed. The members of OR teams were invited to complete a questionnaire including teamwork climate measurement (Safety Attitudes Questionnaire) and their opinion regarding checklist use, checklist audibly reading, and communication change with checklist. Multilevel modeling was performed to investigate the effect of variables related to hospitals and professionals on checklist compliance, after adjustment for patient characteristics.

RESULTS

A checklist was present for 83% of patients, but only 35% demonstrated full completion. Compared with no checklist, full completion was associated with higher safety attitude (high teamwork climate [adjusted odds ratio for full completion, 4.14; 95% confidence interval, 1.75-9.76]; communication change [1.31, 1.04-1.66]; checklist aloud reading [1.16, 1.02-1.32]) and was reinforced by the designation of a checklist coordinator (2.43, 1.06-5.55). Incomplete completion was also associated with enhanced safety attitude contrary to inaccurate completion.

CONCLUSIONS

Compliance with checklists is associated with safer OR team practice and can be considered as an indicator of the extent of safety in OR practice.

Assessing the implementation of community-based learning in public health: a mixed methods approach

BACKGROUND

The French government has set up a community-based learning programme on health promotion for undergraduate health students to involve them in key public health objectives. At the University of Lyon, students first underwent formal instruction, including e-learning, lectures, and interactive seminars, and then became health educators for school pupils. The main objective of the present study was to assess the process of implementing this programme during the 2018-2019 academic year.

METHODS

The satisfaction and perception of medical and midwife students with community-based learning experiences were assessed by a questionnaire, semi-directive interviews, and observations. Replies to the questionnaire were described by median and interquartile range or by proportion. A paired Wilcoxon-Mann-Whitney test was used to compare self-evaluated students' competence scores before and after the seminars (alpha risk of 5%). Thematic analyses using grounded theory were performed on recorded and transcribed interviews, and on transcribed notes taken during the observations.

RESULTS

Over time the students have evolved from a negative perception of the community-based learning to a positive one. The students were mostly satisfied by interactive seminars that allowed them to gain confidence and competencies in health education. Their involvement in the programme increased their self-esteem. They became more aware of their educative responsibilities regarding public health issues as future professionals.

CONCLUSIONS

The students had a positive perception of the implementation of a community-based learning programme in our University, as it appeared a pertinent strategy to raise their awareness of prevention and health education issues.

Improving patient self-reporting of antihypertensive adverse drug events in primary care: a stepped wedge cluster randomised trial

Background

About 25% of patients experience adverse drug events (ADE) in primary care, but few events are reported by the patients themselves. One solution to improve the detection and management of ADEs in primary care is for patients to report them to their general practitioner. The study aimed to assess the effect of a booklet designed to improve communication and interaction between patients treated with anti-hypertensive drugs and general practitioners on the reporting of ADEs.

Methods

A cluster randomized controlled cross-sectional stepped wedge open trial (five periods of 3 months) was conducted. A cluster was a group of general practitioners working in ambulatory offices in France. Adults consulting their general practitioner to initiate, modify, or renew an antihypertensive prescription were included. A booklet including information on cardiovascular risks, antihypertensive treatments, and ADE report forms was delivered by the general practitioner to the patient in the intervention group. The primary outcome was the reporting of at least one ADE by the patient to his general practitioner during the three-month period after enrolment. Two clusters were randomised by sequence for a total of 8 to receive the intervention. An intention-to-treat analysis was conducted. A logistic mixed model with random intercept was used.

Results

Sixty general practitioners included 1095 patients (median: 14 per general practitioner; range: 1–103). More patients reported at least one ADE to their general practitioner in the intervention condition compared to the control condition (aOR = 3.5, IC⁹⁵ [1.2–10.1], p = 0.02). The modification and initiation of an antihypertensive treatment were also significantly associated with the reporting of ADEs (aOR = 4.4, CI⁹⁵ [1.9–10.0], p <  0.001 and aOR = 11.0, CI⁹⁵ [4.6–26.4], p <  0.001, respectively). The booklet delivery also improved patient satisfaction on general practitioner communication and high blood pressure management.

Conclusion

A booklet can improve patient self-reporting of ADEs to their general practitioners. Future research should assess whether it can improve general practitioner management of ADEs and patient’s health status.

Trial registration

Trial registry identifier NCT01610817 (2012/05/30).

Efficacy of parent-mediated communication-focused treatment in toddlers with autism (PACT) delivered via videoconferencing: a randomised controlled trial study protocol

INTRODUCTION

Intervention in the preschool period is currently recommended for autism spectrum disorder. Therapies delivered by parents are particularly suitable for young children. Preschool Autism Communication Trial (PACT) is a parent-mediated therapy that has shown a significant and sustained impact on autism symptom reduction. However, access to such evidence-based therapies for families is limited due to autism centres located in large urban areas. Using videoconferencing to deliver PACT training to parents may improve accessibility for families living in underserved areas.

METHODS AND ANALYSIS

This single-blind randomised controlled trial, involving six sites in France, will investigate the efficacy of a telehealth, videoconferencing-based, parent-mediated PACT therapy on autism symptoms, over a 12-month period. It will compare PACT plus treatment as usual (TAU) against TAU only in a cohort of 238 toddlers (119 per group) aged 18-36 months at inclusion and living with their families more than 40 min away from the specialist centres for autism. Primary outcome will include change of overall autism score on the Autism Diagnostic Observation Scale (ADOS) at 12 months. Secondary outcomes will measure change in child skills, child functioning, impact on parents (stress, health, priorities) and implementation characteristics. Repeated measures analyses will be used to test the effect of PACT intervention on the overall ADOS module 1 score over the 12-month study period. Linear mixed models will be used with time, treatment allocation and the interaction between treatment and time as fixed effects and individual variation as random effect.

ETHICS AND DISSEMINATION

This protocol (V.5, date: 25 October 2019) is approved by the French National Review Board (reference no 2018-A02516-49). The results will be disseminated via peer-reviewed journals TRIAL REGISTRATION NUMBER: NCT04244721.

Strategies used by emergency care professionals to handle interpersonal difficulties with patients: a qualitative study

OBJECTIVES

Identify the strategies implemented by emergency care professionals when facing tension and interpersonal violence from patients and their friends and family.

DESIGN

Descriptive qualitative study based on 38 semidirective interviews.

PARTICIPANTS

Doctors, nurses, nursing assistants and administrative staff.

SETTING

Four emergency departments (EDs) from three French university hospitals.

RESULTS

According to the medical professionals interviewed, the difficulties that they encounter with patients or their accompanying family members can be explained by a lack of understanding of the functioning of EDs, by a general increase in individualistic behaviours leading to a lack of civility or by deviant behaviours (related to toxic substance abuse or mental illness). While managing deviant behaviours may sometimes require a collective intervention, ED staff also implement what are essentially individual communication strategies (with the use of rational explanation, seduction and empathy), confrontation or flight to deal with interpersonal difficulties.

CONCLUSIONS

Strategies used by staff members tend to be individualised for the most part, and some, such as confrontational or escape strategies, may not be adapted to all situations. In the face of difficulties between staff and patients, mediators, specialised in resolving conflict, could entrust some cases to professionals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03139110).

A Nurse-Led Bridging Program to Reduce 30-Day Readmissions of Older Patients Discharged From Acute Care Units

OBJECTIVES

Older hospitalized patients are at high risk of early readmissions, requiring the implementation of enhanced coordinated transition programs on discharge. The objective of this study was to evaluate the impact of a nurse-led transition bridging program on the rate of unscheduled readmissions of older patients within 30 days from discharge from geriatric acute care units.

DESIGN

A stepped-wedge cluster randomized trial.

SETTING AND PARTICIPANTS

Seven hundred five patients aged ≥75 years hospitalized in one of 10 acute geriatric units, with at least 2 readmission risk-screening criteria (derived from the Triage Risk Screening Tool), were included from July 2015 to August 2016.

METHODS

The intervention condition consisted in a nurse-led hospital-to-home bridging program with 4 weeks postdischarge follow-up (2 home visits and 2 telephone calls). Unscheduled hospital readmission or emergency department (ED) visits were compared in intervention and control condition within 30 days from discharge.

RESULTS

The rate of 30-day readmission or ED visit was 15.5% in the intervention condition vs 17.6% in the control condition [hazard ratio stratified on clusters: 0.61 (upper limit unilateral 95% confidence interval = 1.11), P = .09]. Rate of presence of professional caregivers was increased in the intervention condition (P < .001).

CONCLUSIONS AND IMPLICATIONS

Although the intervention resulted in an increase in the rate of implementation of a package of care at the 4-week of follow-up, we could not demonstrate a reduction in the rate of 30-day readmissions or ED visits of older patients at risk of readmission. These findings support the evaluation of this type of program on the longer term.

[Mediators in emergency services: what missions according to the staff?]

OBJECTIVES

Violence in emergency services has become a central issue in the daily work of hospital employees. While the use of video surveillance and the training of professionals in conflict management are the most common methods used, there are few cases using the setting up of a third part such as a mediator. We conducted a qualitative study with professionals to examine their representations associated with mediation.

METHOD

Semi-directive interviews were conducted with professionals from four emergency units. The topics discussed in interviews were the definition of mediation and the missions that the mediators should fulfil. The content of 38 semi-directive interviews was analysed according to the inductive approach of the grounded theory. A content analysis was made, followed by an analysis aiming to bring out types and convergences/divergences.

RESULTS

Professionals were not aware of the definition of mediation and of its missions. They linked to it an instrumental theme, making mediation a tool for conflict prevention and management, a tool for communication with patients about their care, and about the organisation of emergency unit. The upcoming presence of mediators was seen as an help. A potential competition between professionals and mediators in the tasks performed was identified.

CONCLUSION

The study shows a favourable opinion towards mediation. It has allowed to identify obstacles to the well-functioning of the missions assigned to mediators. One of the challenges is the integration of this new actor, the mediator.

Impact of a paediatric-adult care transition programme on the health status of patients with sickle cell disease: study protocol for a randomised controlled trial (the DREPADO trial)

BACKGROUND

Thanks to advancements in medical care, a majority of patients with sickle cell disease (SCD) worldwide live beyond 18 years of age, and therefore, patients initially followed in paediatric departments are then transferred to adult departments. This paediatric-adult care transition is a period with an increased risk of discontinuity of care and subsequent morbidity and mortality. During this period, the patient will have to manage new interlocutors and places of care, and personal issues related to the period of adolescence. To take into consideration all these aspects, an interesting approach is to use the whole system approach to the patient, as presented in the biopsychosocial approach. The aim of this trial is to evaluate the impact of the proposed biopsychosocial paediatric-adult transition programme.

METHODS

The DREPADO study is a multicentre randomised control trial comparing a control group (Arm A) to an interventional group with a paediatric-adult transition programme based on a biopsychosocial approach (Arm B). To be included, patients should have the SS, SC, or Sβ form of sickle cell disease and be aged between 16 and 17 years. The randomisation in a 1:1 ratio assigns to Arm A or B. The primary outcome is the number of hospital admissions and emergencies for complications in the index hospital, in the 2 years after the first consultation in the adult department of care. Secondary outcomes consider the quality of life, but also include coping skills such as sense of self-efficacy and disease knowledge. To provide patient and parent knowledge and coping skills, the transition programme is composed of three axes: educational, psychological, and social, conducted individually and in groups.

DISCUSSION

By providing self-care knowledge and coping skills related to SCD and therapeutics, helping empower patientsin relation to pain management and emotions, and facilitating the relationship to oneself, others, and care in Arm B of the DREPADO study, we believe that the morbidity and mortality of patients with SCD may be reduced after the proposed paediatric-adult transition programme.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03786549; registered on 17 December 2018; https://clinicaltrials.gov/.

Breastfeeding peer counselling for mothers of preterm neonates: protocol of a stepped-wedge cluster randomised controlled trial

INTRODUCTION

Among preterm infants, mother's own milk feeding reduces neonatal morbidity and decreases the length of hospital stay. However, breastfeeding rates and duration are lower than among term infants. It is reported that peer counselling is effective in increasing breast feeding in term infants in low-income and middle-income countries, but results are mixed in high-income countries. We aim to investigate herein whether peer counselling may be a feasible and effective breastfeeding support among preterm infants in French-speaking high-income countries.

METHODS AND ANALYSIS

Eight European centres will participate in this stepped-wedge cluster randomised controlled trial. We plan to include 2400 hospitalised neonates born before 35 gestational weeks. Each centre will begin with an observational period. Every 3 months, a randomised cluster (centre) will begin the interventional period with peer counsellors until the end of the study. The counsellors will be trained and supervised by the trained nurses. They will have a weekly contact with participating mothers, with a face-to-face meeting at least once every fortnight. During these meetings, peer counsellors will listen to mothers' concerns, share experiences and help the mother with their own knowledge of breast feeding. The main outcome is breastfeeding rate at 2 months corrected age. Secondary outcomes are breastfeeding rates at hospital discharge and at 6 months, breastfeeding duration and severe neonatal morbidity and mortality. The mental health of the mother, mother-infant bonding and infant behaviour will be assessed using self-report questionnaires. A neurodevelopmental follow-up, a cost-effectiveness analysis and a cost-consequence at 2 years corrected age will be performed among infants in a French subgroup.

ETHICS AND DISSEMINATION

French, Belgian and Swiss ethics committees gave their agreement. Publications in peer-reviewed journals are planned on breast feeding, mental health and economic outcomes.

TRIAL REGISTRATION NUMBER

NCT03156946.

Assessing the performance of indicators during their life cycle: the mixed QUID method

Background

Quality indicators (QI) are mandatory in French hospitals. After a decade of use, the Ministry of Health set up an expert workgroup to enhance informed decision-making regarding currently used national QI, i.e. to propose a decision of withdrawing, revising or continuing their use. We report the development of an integrated method for a comprehensive appraisal of quality/safety indicators (QI) during their life cycle, for three purposes, quality improvement, public disclosure and regulation purposes. The method was tested on 10 national QI on use for up to 10 years to identify operational issues.

Methods

A modified Delphi technique to select relevant criteria and a development of a mixed evaluation method by the workgroup. A ‘real-life’ test on 10 national QI.

Results

Twelve criteria were selected for the appraisal of QI used for regulation goals, 11 were selected for hospital improvement and seven for public disclosure. The perceived feasibility and relevance were studied including hospital workers, patients and health authorities professionals; the scientific soundness of the indicator development phase was reviewed by analyzing reference documents; the metrological performance (limited to the discriminatory power and dynamics of change during the life cycle dimensions) was analyzed on the national datasets.

Applied to the 10 QI, the workgroup proposed to withdraw four of them and to modify or suspend the six others.

Conclusions

The value of the method was supported by the clear-cut conclusions and endorsement of the proposed decisions by the health authorities.

Impact of a comprehensive prevention programme aimed at reducing incivility and verbal violence against healthcare workers in a French ophthalmic emergency department: an interrupted time-series study

OBJECTIVE AND SETTING

Primary prevention, comprising patient-oriented and environmental interventions, is considered to be one of the best ways to reduce violence in the emergency department (ED). We assessed the impact of a comprehensive prevention programme aimed at preventing incivility and verbal violence against healthcare professionals working in the ophthalmology ED (OED) of a university hospital.

INTERVENTION

The programme was designed to address long waiting times and lack of information. It combined a computerised triage algorithm linked to a waiting room patient call system, signage to assist patients to navigate in the OED, educational messages broadcast in the waiting room, presence of a mediator and video surveillance.

PARTICIPANTS

All patients admitted to the OED and those accompanying them.

DESIGN

Single-centre prospective interrupted time-series study conducted over 18 months.

PRIMARY OUTCOME

Violent acts self-reported by healthcare workers committed by patients or those accompanying them against healthcare workers.

SECONDARY OUTCOMES

Waiting time and length of stay.

RESULTS

There were a total of 22 107 admissions, including 272 (1.4%) with at least one act of violence reported by the healthcare workers. Almost all acts of violence were incivility or verbal harassment. The rate of violence significantly decreased from the pre-intervention to the intervention period (24.8, 95% CI 20.0 to 29.5, to 9.5, 95% CI 8.0 to 10.9, acts per 1000 admissions, p<0.001). An immediate 53% decrease in the violence rate (incidence rate ratio=0.47, 95% CI 0.27 to 0.82, p=0.0121) was observed in the first month of the intervention period, after implementation of the triage algorithm.

CONCLUSION

A comprehensive prevention programme targeting patients and environment can reduce self-reported incivility and verbal violence against healthcare workers in an OED.

TRIAL REGISTRATION NUMBER

NCT02015884.

Cystic fibrosis-related diabetes before lung transplantation is associated with lower survival but does not affect long-term renal function

OBJECTIVE

To describe the prevalence of cystic fibrosis-related diabetes (CFRD) before and after lung transplantation (LT); to analyse the survival and renal function after LT according to the CFRD status before LT.

METHODS

Sixty cystic fibrosis (CF) patients transplanted at the Lyon University Hospital between 2004 and 2014 were included. Genotype, pancreatic status, age at LT, survival were recorded. Glucose tolerance status, daily insulin dose requirement, glomerular filtration rate (GFR), and daily glucocorticoid (GC) dose were recorded before LT and until December 2016.

RESULTS

The median follow-up was 5.6 (3.8-8.2) years, and nine patients died. Survival was poorest for patients with CFRD before LT compared with those without CFRD (P = 0.03) but was not correlated with the GFR before LT, with sex, age at LT, or CF genotype. The prevalence of CFRD was 68% at 2 years and 54% at 5 years. For persistent insulin-treated CFRD, the insulin requirement decreased (-2.1 IU/d/y; P < 0.01) and was correlated with the daily GC dose (+0.4 IU/d for one additional milligram, P = 0.012). Seven (11%) patients who had insulin-treated CFRD before LT became nondiabetic after LT, with a median time of 2 (1-4) years. After LT, the GFR decreased (-5.3 ml/min/1.73 m ² /y; P < 0.001) and was not correlated with the CFRD status before LT.

CONCLUSIONS

CFRD before LT is associated with poor survival after LT, which should lead to better management of diabetes. Some patients with pre-LT CFRD became nondiabetic after LT. CFRD is not associated with renal insufficiency after LT.

Improving the safety climate in hospitals by a vignette-based analysis of adverse events: a cluster randomised study

OBJECTIVE

To assess the impact of a vignette-based analysis of adverse events (AEs) on the safety climate (SC) of care units.

DESIGN

Prospective, open, cluster (a unit) randomised controlled trial.

SETTING

Eighteen acute care units of seven hospitals in France.

PARTICIPANTS

Healthcare providers who worked in the units.

INTERVENTION

Vignette-based analyses of AEs were conducted with unit's providers once per month for six consecutive months. The AEs were real cases that occurred in other hospitals. The hospital risk manager conducted each analysis as follows: analysis of the immediate and root causes of the AE; assessment of the care unit's vulnerabilities and existing barriers in the occurrence of an identical AE and search for solutions.

MAIN OUTCOME MEASURE

SC was measured using the French version of the Hospital Survey on Patient Safety Culture questionnaire. The primary outcome was the difference in the 'Organisational learning and continuous improvement' dimension score, from before to after the analyses.

RESULTS

Median participation rate in the analyses was 20% (range: 7-45%). Before intervention, the response rate to the SC survey was 80% (n = 210) in the intervention group and 73% (n = 191) in the control group. After intervention, it was 59% (n = 141) and 63% (n = 148), respectively. The dimension score evolved differently for the groups from before to after intervention (intervention: +10.2 points ±8.8; control: -3.0 points ±8.5, P = 0.04). Side effects were not measured.

CONCLUSIONS

Vignette-based analysis was associated with the improvement of the perception of participants regarding their institution's capacity for organisational learning and continuous improvement.

Hospital survey on patient safety culture (HSOPS): variability of scoring strategies

Objective

To assess the variability of safety culture dimension scores and their associated rankings depending on three different scoring strategies using the Hospital Survey On Patient Safety Culture (HSOPS).

Design

Cross-sectional study using a self-administered questionnaire.

Setting

The study was conducted in an 1836-bed acute-care French university hospital with an annual volume of 135 999 stays, between April 2013 and November 2014.

Participants

All caregivers and technical-administrative staff with at least 6 months of employment, spending at least half of their working time in the hospital, were asked to participate.

Intervention

None.

Main outcome measure

The variability of the HSOPS results using three different scoring methods: the percentage of positive responses recommended by the Agency for Healthcare Research and Quality, the averaged individual means and the averaged individual sums.

Results

The response rate was 78.6% (n = 3978). The percentage of positive responses resulted in lower scores compared to averaged individual means and averaged individual sums in the six least developed dimensions, and gave more widely spread scores and greater 95CIs in the six most developed dimensions. Department rankings also varied greatly depending on the scoring methods.

Conclusion

The values of the HSOPS scores and their corresponding rankings greatly depended on the computation method. This finding shows how important it is to agree on the use of the same scoring strategies, before broadly comparing results within and across organizations.

The emergence of patient safety issues in France

INTRODUCTION

The objective of this study was to elucidate the conditions of emergence of patient safety issues in the public debate and the limits to implementation of patient safety in the current health system.

METHOD

A narrative review of the international literature was conducted by searching PubMed, Cairn and Persée databases.

RESULTS

The database search retrieved 2,206 documents, 48 of which were included in the study. The theme of patient safety has spread worldwide, but emerged late in France. The delayed emergence of patient safety in France is essentially related to the euphemistic approach to the problem of patient safety, the difficulty of adopting systematic reasoning, the lack of human resources management levers and the ambiguous position of patients in relation to patient safety.

Upper limb and hand patterns in cerebral palsy: Reliability of two new classifications

AIM

To evaluate the inter- and intra-rater reliability of two previously developed classifications of upper limb and hand patterns.

METHOD

Two hundred and twelve films of patients with CP (118 of UL postures and 94 of hand tasks; median age 14, 3-46 years) were viewed by 18 examiners from 2 different rehabilitation centers, and one expert who had participated in the design of the classifications. They classed upper limb (3 patterns with sub-types) and hand patterns (2 patterns with subtypes) twice, at 2 months' interval. Inter- and intra-rater reliability were analysed.

RESULTS

Intra-rater and inter-rater reliability were very high for upper limb and hand patterns (0.87 < k < 0.92), and high for the subtypes (0.58 < k < 0.68). Examiners stated that both classifications were useful and feasible in clinical practice.

INTERPRETATION

Despite the single, short training session on use of the classifications, agreement between the examiners and the expert examiner was good to high, confirming that these classifications are easy to use and reliable. The classifications proposed here provide homogenous terminology for use in both clinical practice and research, to describe, evaluate and follow-up changes in upper limb and hand patterns in patients with cerebral palsy, particularly those with dyskinesia.

Impact of the Early Start Denver Model on the cognitive level of children with autism spectrum disorder: study protocol for a randomised controlled trial using a two-stage Zelen design

INTRODUCTION

Early intervention for autism spectrum disorder (ASD) in the European French-speaking countries is heterogeneous and poorly evaluated to date. Early intervention units applying the Early Start Denver Model (ESDM) for toddlers and young children with ASD have been created in France and Belgium to improve this situation. It is essential to evaluate this intervention for the political decision-making process regarding ASD interventions in European French-speaking countries. We will evaluate the effectiveness of 12 hours per week ESDM intervention on the cognitive level of children with ASD, over a 2-year period.

METHODS AND ANALYSIS

The study will be a multicentre, randomised controlled trial, using a two-stage Zelen design. Children aged 15-36 months, diagnosed with ASD and with a developmental quotient (DQ) of 30 or above on the Mullen Scale of Early Learning (MSEL) will be included. We will use a stratified minimisation randomisation at a ratio 1:2 in favour of the control group. The sample size required is 180 children (120 in the control and 60 in the intervention group). The experimental group will receive 12 hours per week ESDM by trained therapists 10 hours per week in the centre and 2 hours in the toddlers' natural environment (alternatively by the therapist and the parent). The control group will receive care available in the community. The primary outcome will be the change in cognitive level measured with the DQ of the MSEL scored at 2 years. Secondary outcomes will include change in autism symptoms, behavioural adaptation, communicative and productive language level, sensory profile and parents' quality of life. The primary analysis will use the intention-to-treat principle. An economic evaluation will be performed.

DISSEMINATION

Findings from the study will be disseminated through peer reviewed publications and meetings.

TRIAL REGISTRATION NUMBER

NCT02608333 (clinicaltrials.gov); Pre-results.

Assessment of patient safety culture: what tools for medical students?

BACKGROUND

The assessment of patient safety culture refers mainly to surveys exploring the perceptions of health professionals in hospitals. These surveys have less relevance when considering the assessment of the patient safety culture of medical students, especially at university or medical school. They are indeed not fully integrated in care units and constitute a heterogeneous population. This work aimed to find appropriate assessment tools of the patient safety culture of medical students.

METHODS

Systematic review of the literature. Surveys related to a care unit were excluded. A typology of the patient safety culture of medical students was built from the included surveys.

RESULTS

Eighteen surveys were included. In our typology of patient safety culture of medical students (15 dimensions), the number of dimensions explored by survey (n) ranged from 1 to 12, with 6 "specialized" tools (n ≤ 4) and 12 "global" tools (N ≥ 5). These surveys have explored: knowledge about patient safety, acknowledgment of the inevitability of human error, the lack of skills as the main source of errors, the errors reporting systems, disclosure of medical errors to others health professionals or patients, teamwork and patient involvement to improve safety in care.

CONCLUSIONS

We recommend using Wetzel's survey for making an overall assessment of the patient safety culture of medical students at university. In a specific purpose-e.g. to assess an educational program on medical error disclosure-the authors recommend to determine which dimensions of patient safety will be taught, to select the best assessment tool. Learning on patient safety should however be considered beyond the university. International translations of tools are required to create databases allowing comparative studies.

Cluster randomized trial to evaluate the impact of team training on surgical outcomes

Background

The application of safety principles from the aviation industry to the operating room has offered hope in reducing surgical complications. This study aimed to assess the impact on major surgical complications of adding an aviation-based team training programme after checklist implementation.

Methods

A prospective parallel-group cluster trial was undertaken between September 2011 and March 2013. Operating room teams from 31 hospitals were assigned randomly to participate in a team training programme focused on major concepts of crew resource management and checklist utilization. The primary outcome measure was the occurrence of any major adverse event, including death, during the hospital stay within the first 30 days after surgery. Using a difference-in-difference approach, the ratio of the odds ratios (ROR) was estimated to compare changes in surgical outcomes between intervention and control hospitals.

Results

Some 22 779 patients were enrolled, including 5934 before and 16 845 after team training implementation. The risk of major adverse events fell from 8·8 to 5·5 per cent in 16 intervention hospitals (adjusted odds ratio 0·57, 95 per cent c.i. 0·48 to 0·68; P &lt; 0·001) and from 7·9 to 5·4 per cent in 15 control hospitals (odds ratio 0·64, 0·50 to 0·81; P &lt; 0·001), resulting in the absence of difference between arms (ROR 0·90, 95 per cent c.i. 0·67 to 1·21; P = 0·474). Outcome trends revealed significant improvements among ten institutions, equally distributed across intervention and control hospitals.

Conclusion

Surgical outcomes improved substantially, with no difference between trial arms. Successful implementation of an aviation-based team training programme appears to require modification and adaptation of its principles in the context of the the surgical milieu. Registration number: NCT01384474 (http://www.clinicaltrials.gov).

Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial

Background

In France, for patients aged 75 or older, it has been estimated that the hospital readmission rate within 30 days is 14 %, a quarter being avoidable. Some evidence suggests that interventions “bridging” the transition from hospital to home and involving a designated professional (usually nurses) are the most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a care transition program from hospital to home for elderly admitted to short-stay units.

Methods

This is a multicentre, stepped-wedge cluster randomised trial.

The program will be implemented at three times of the transition: 1) during the patient’s stay in hospital: development of a discharge plan, creation of a transitional care file, and notification of the primary care physician about inpatient care and hospital discharge by the transition nurse; 2) on the day of discharge: meeting between the transition nurse and the patient to review the follow-up recommendations; and 3) for 4 weeks after discharge: follow-up by the transition nurse.

The primary outcome is the 30-day unscheduled hospital readmission or emergency visit rate after the index hospital discharge.

The patients enrolled will be aged 75 or older, hospitalized in an acute care geriatric unit, and at risk of hospital readmission or an emergency visit after returning home.

In all, 630 patients will be included over a 14-month period. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded.

Discussion

Our study makes it possible to evaluate the specific effect of a bridging intervention involving a designated professional intervening before, during, and after hospital discharge.

The strengths of the study design are methodological and practical. It permits the estimation of the intervention effect using between- and within-cluster comparisons; the study of the fluctuations in unscheduled hospital readmission or emergency visit rates; the participation of all clusters in the intervention condition; the implementation of the intervention in each cluster successively.

Trial Registration

This study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02421133). Registered 9 March 2015.

Sarcoidosis and lymphoma: a comparative study

AIM

To assess the clinical features and outcome of lymphoma when associated with sarcoidosis and to determine whether this association gives lymphoma a better prognosis.

DESIGN

Multicentre retrospective cohort study.

METHODS

Retrospective chart review.

RESULTS

Twenty-one patients were included (9 males, 12 females). Median age at sarcoidosis diagnosis was 48 years (range: 24-68 years). In 14 cases, lymphoma occurred within a previously known sarcoidosis. Five patients received a concomitant diagnosis of sarcoidosis and lymphoma, whereas lymphoma preceded sarcoidosis in two patients. Three patients were diagnosed with Hodgkin's lymphoma and 18 patients with non-Hodgkin's lymphoma (diffuse large B-cell lymphoma (DLBCL) (n = 11), follicular lymphoma (n = 2), chronic lymphocytic leukemia/small lymphocytic lymphoma (n = 2), anaplastic large cell lymphoma ALK + (n = 1), angioimmunoblastic T-cell lymphoma (n = 1) and T-cell prolymphocytic leukemia (n = 1)). Thirteen patients were alive and in complete remission. Median age at the time of diagnosis of sarcoidosis was lower in patients with concomitant lymphoma compared with patients with sarcoidosis preceding lymphoma (34 years vs. 51 years, P = 0.01). Patients presenting with DLBCL associated with sarcoidosis were compared with DLBCL without sarcoidosis. No statistical difference was found in the risk of death or progression between the two groups (P = 0.685).

CONCLUSIONS

We report here the largest series of lymphoma associated sarcoidosis patients. As opposed to previous studies, we observed a predominance of patients with DLBCL. Our study confirms the concept of the sarcoidosis-lymphoma syndrome. Large B-cell lymphoma does not have a better prognosis when associated with sarcoidosis.

Incorrect evaluation of the frequency of malnutrition and of its screening in hospitalized children by health care professionals

RATIONALE, AIMS AND OBJECTIVES

Malnutrition screening is essential to detect and to treat patients with stunting or wasting. The aim was to evaluate the subjective perception of frequency and assessment of malnutrition by health care professionals.

RESEARCH METHODS AND PROCEDURES

In a paediatric university hospital, a cross-sectional survey was conducted with a Likert scale approach to health care professionals and compared with objective measurements on a given day of frequency of malnutrition and of its screening.

RESULTS

279 health care professionals participated. The malnutrition rate, estimated versus measured, was 16.8% and 34.8%, respectively. Conversely, the estimated frequency of malnutrition screening versus measured frequency was 80.6% versus 43.1%, respectively. Furthermore, the perception of health care professionals did not differ depending on their professional category or speciality.

CONCLUSIONS

In conclusion, health care staff underestimates the prevalence of malnutrition in children by half and overestimates the frequency of appropriate screening practices for detection of malnutrition. This flawed/unreliable perception may disrupt both screening and the management of malnourished children. There is an urgent need to find out the reasons behind these errors caused by subjective perception in order to develop appropriate educational training to remedy the situation.

Implementation of a computerized system in pediatric wards to improve nutritional care: a cluster randomized trial

BACKGROUND/OBJECTIVES

Malnutrition occurs frequently in hospitalized children. We aimed to assess whether a computerized system could lead to improved clinical practices in malnourished children.

SUBJECTS/METHODS

Healthcare workers (242) from six departments in a pediatric university hospital participated in a cluster randomized trial, studying 1457 malnourished children hospitalized from September 2009 to August 2011. Following a baseline observational pre-intervention period, all departments were randomized into either intervention or control arms. A computerized malnutrition-screening system was implemented in the intervention group to automatically trigger a dietetic referral in real time. Furthermore, the nutrition support team conducted an awareness campaign with healthcare workers and a leadership-based strategy to reinforce the message during the entire study period. Adherence to practice guidelines (daily weights, investigation of etiology for malnutrition, management by a dietitian and application of refeeding protocols) was compared between pre- and post-intervention periods in both the intervention and trial arms.

RESULTS

When compared with the pre-intervention period, the clinical practices were significantly improved within the intervention arm for every outcome (P<0.01), whereas remained unchanged in the control arm. In addition, during the post-intervention period, malnutrition etiology investigation by physicians (adjusted odds ratio (OR) of 4.4, 95% confidence interval (CI) 1.7-11.8, P=0.003) and management by a dietitian (OR 2.7, 95% CI 1.0-6.9, P=0.046) occurred more frequently in the intervention clusters.

CONCLUSIONS

Implementation of an electronic system to detect malnutrition in real time was associated with a rapid improvement in clinical practices for better care of hospitalized children.

Validation of the French version of the Hospital Survey on Patient Safety Culture questionnaire

OBJECTIVE

To assess the psychometric properties of the French version of the Hospital Survey on Patient Safety Culture questionnaire (HSOPSC) and study the hierarchical structure of the measured dimensions.

DESIGN

Cross-sectional survey of the safety culture.

SETTING

18 acute care units of seven hospitals in South-western France.

PARTICIPANTS

Full- and part-time healthcare providers who worked in the units.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Item responses measured with 5-point agreement or frequency scales. Data analyses A principal component analysis was used to identify the emerging components. Two structural equation modeling methods [LInear Structural RELations (LISREL) and Partial Least Square (PLS)] were used to verify the model and to study the relative importance of the dimensions. Internal consistency of the retained dimensions was studied. A test-retest was performed to assess reproducibility of the items.

RESULTS

Overall response rate was 77% (n = 401). A structure in 40 items grouped in 10 dimensions was proposed. The LISREL approach showed acceptable data fit of the proposed structure. The PLS approach indicated that three dimensions had the most impact on the safety culture: 'Supervisor/manager expectations & actions promoting safety' 'Organizational learning-continuous improvement' and 'Overall perceptions of safety'. Internal consistency was above 0.70 for six dimensions. Reproducibility was considered good for four items.

CONCLUSIONS

The French HSOPSC questionnaire showed acceptable psychometric properties. Classification of the dimensions should guide future development of safety culture improving action plans.

Multifaceted intervention to enhance the screening and care of hospitalised malnourished children: study protocol for the PREDIRE cluster randomized controlled trial

BACKGROUND

Hospital malnutrition is an underestimated problem and as many as half of malnourished patients do not receive appropriate treatment. In order to extend the management of malnutrition in health care facilities, multidisciplinary teams focusing on clinical nutrition were established in France. The establishment of such teams within hospital facilities remains nonetheless difficult. We have consequently developed a multifaceted intervention coordinated by a Nutritional Support Team (NST). Our study aims to evaluate the impact of this multifaceted intervention coordinated by a NST, in adherence to recommended practices for the care of malnourished children, among health care workers of a paediatric university hospital.

METHODS/DESIGN

We carried out 1) a six-month observational phase focusing on the medical care procedures relative to malnourished children followed by 2) a cluster randomised controlled trial phase to evaluate the impact of a multidisciplinary nutrition team over an 18 month time frame.Based on power analyses and assuming a conservative intracluster correlation coefficient, 1289 children were needed to detect a 25% difference in rates between the two groups of the cluster trial.The implementation of our intervention was coordinated by the NST and had three major components: a) access to a computerised malnutrition screening system associated with an automatic alert system, b) an awareness campaign directed toward the health care workers and c) a leadership based strategy.Main outcomes included the number of daily weighings during hospitalisation, the investigation of malnutrition etiology and the management of malnutrition by a dietician and/or the NST.Due to the clustered nature of the data with children nested in departments, a generalized estimated equations approach will be used to analyse the impact of the multifaceted intervention on primary and secondary outcomes.

DISCUSSION

Our results will provide an overall response regarding the effectiveness of our multifaceted intervention and we should be able to suggest an organization and mode of operation of NST.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01081587.

Development of a safety culture: initial measurements at six hospitals in France

A cross-sectional and descriptive survey of a safety culture (SC) was conducted in 20 clinical units in France. A self-administered questionnaire measuring 12 dimensions of safety culture was given to healthcare professionals. The overall response rate was 65%. The poorly developed dimensions of safety culture that were identified were nonpunitive response to error, staffing, management support for patient safety, handoffs, and transitions.

Outbreak of staphylococcal bullous impetigo in a maternity ward linked to an asymptomatic healthcare worker

An outbreak of staphylococcal bullous impetigo occurred over a period of five months in a maternity ward involving seven infected and two colonised neonates. The skin lesions were due to epidermolytic toxin A-producing Staphylococcus aureus. Infection control measures were implemented and a retrospective case-control study performed. Contact with an auxiliary nurse was the only risk factor for cases of bullous impetigo (P<0.01). The nurse cared for all seven cases and was an asymptomatic nasal carrier of the epidemic strain. Repeated courses of decontamination treatment failed to eradicate carriage. Nine months after the last case, another neonate developed a more severe form of bullous impetigo and the auxiliary nurse was reassigned to an adult ward.