Hospital hand hygiene after COVID-19: has the pandemic heightened healthcare workers’ awareness?

Background

Hand hygiene (HH) is the leading measure for preventing the transmission of healthcare-associated infections (HAI), and a cornerstone to prevent COVID-19 spread. Aim of the research was the assessment of HCWs’ adherence to the application of WHO optimal practices, with the goal to promote a culture of safety and quality infection prevention and control (IPC) activities.

Methods

Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, implemented a HH monitoring plan in which HCWs’ adherence to HH procedures is evaluated using WHO guidelines, technical manual and observation form. Direct field observations took place in March and April 2022 by trained personnel. Process index was HH adherence, stratified by profession, opportunity and unit, which has been visited at least twice.

Results

Overall, 302 HCWs were observed from 18 hospital units (105 physicians, 108 nurses, 84 healthcare assistants and 5 students). Out of 1382 opportunities, global adherence was 52% with 190 handwashing and 598 hand rubbing. The indication with the highest adherence was “after body fluid exposure risk” (76%), whereas the lowest were “after touching the patient's setting” (40%) and “before touching a patient” (43%). Adherence was higher in specialistic surgeries and haematology units, while the worst performances were reported in general medicine ward (29%). Physicians’ and nurses’ adherence was respectively 45% and 61%. Audits occasionally revealed non-conformities in glove use (i.e., unnecessary use, not changed between patients, hand rubbing on gloves).

Conclusions

These preliminary findings could be directly linked to habits acquired during the pandemic, when HW tended to consider COVID-19 patients as a unique block to shield themselves from infections, rather than safeguarding individual patient units. HH awareness could have changed in the wake of COVID-19 pandemic and our study described how HCWs’ adherence to optimal practices needs specific initiatives to promote correct HH.

Key messages

• The COVID‐19 pandemic reinforced the importance of handwashing and IPC, showing the key role of the HCWs’ adherence to hand hygiene (HH) procedures.

• HH audits play a leading part in clinical governance and IPC, aiming at enhancing the quality of care and patient safety, particularly to strengthen health system resilience in post-COVID era.

Hospital discharge for stroke patients: Transitional Care is Brain

Background

Among cerebrovascular disease, stroke is a life-threatening neurological event and a main cause of serious long-term disability, with relevant healthcare and economic burden. Treatment of stroke is time dependent and organised integrated stroke care enables quick and effective responses to reduce stroke-related death and disability. This study aimed at evaluating the amount of hospital discharge to transitional care facilities for stroke patients to support integrated care models in the city of Pavia (Italy).

Methods

In 2017 in Pavia, Fondazione IRCCS Policlinico San Matteo started a partnership with Fondazione Mondino to build a specific stroke pathway, becoming a leading centre for stroke treatment. We conducted a retrospective chart review (RCR) of patient-centred data to quantify the volume of discharge for stroke patients. Two trained public health residents reviewed medical records with stroke admission diagnosis during 2021, analysing onset (e.g., Emergency Room, other hospital, emergency network), ward, treatment and discharge types (e.g., home, death, transitional care facility).

Results

Our RCR found 669 patients with a stroke diagnosis treated at San Matteo hospital in 2021, the vast majority of which were admitted to the neurology ward (375 patients, 56%). The recanalization rate was 32% (150 on 464 ischemic stroke patients). Regarding the discharge type, 299 patients (45%) were sent home, while 297 patients (44%) needed transfer to rehabilitation or long-term care facilities. About 8% (52 patients) of the overall sample died in hospital.

Conclusions

Our analysis showed that, while most stroke patients were discharged and sent home, more than two-third need to be transferred to continue to get the right healthcare from the right professional. Transitional care facilities should receive the greatest consideration by systems and providers seeking to implement care models to reduce residual neurological disabilities for stroke patients.

Key messages

• A fast and accessible emergency chain is essential to reduce residual neurological disabilities and the related healthcare and economic burden in stroke patients.

• Extending the stroke path model to other time-dependent diseases is increasingly high-priority to shape a strong and resilient healthcare system, ensuring qualified health coverage.

P270 TELL ME HOW LONG WILL YOU STAY … TELL ME HOW LONG HOW LONG … ANALYSIS OF THE DURATION OF HOSPITAL STAY (HOSPITAL LENGTH OF STAY) OF ELDERLY PATIENTS WITH EMBOLISM: EXPERIENCE OF 4 YEARS IN FIRST AID

Premise

Pulmonary embolism is a disease still characterized by high mortality. It requires emergency department resources to be diagnosed promptly and can require lengthy hospital care.

Purpose

to assess which parameters, in the real life of an Emergency Department, correlate with the duration of a hospitalization for pulmonary embolism (hospital LOS).

Methods

Single–center retrospective observational study, on all geriatric patients (> 75) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We analyzed all the blood chemistry and blood gas analyzes performed upon access to the emergency room. We then had all chest CTs retested by an experienced radiologist. We also analyzed vital parameters and the various shock indexes from these derivatives. We then analyzed whether patients had massive pulmonary embolism or the presence of organ damage (right ventricular dilation, pulmonary artery dilation and presence of pulmonary infarction).

Results

We enrolled 247 patients, all in need of hospitalization for acute pulmonary embolism. The average age is 83 with female precalence (F = 63%). Regarding the length of hospital stay, the presence of massive embolism shows a good statistical correlation (p < 0.01), while the presence of organ damage seems irrelevant (p > 0.05). The need for resuscitation care and the high sPESI index also show no correlation (p > 0.05). Age and vital signs (blood pressure, respiratory rate, heart rate) as well as derived shock indices are unrelated (rho∼0; p > 0.05). A weak correlation is instead present with high D–Dimer values (rho∼0.20; p < 0.005) while the other blood samples do not show correlation (rho∼0; p > 0.05). No correlation for the blood gas analysis parameters taken into consideration (pH; pO2; pCO2; lactates).

Conclusions

The study suggests that the presence of massive pulmonary embolism and to a lesser extent high D–Dimer values correlates with a long hospital stay.

P263 ROLE OF VITAL SIGNS AND INDICES OF SHOCK DERIVED FROM THEM IN THE SUSPICION OF MASSIVE PULMONARY EMBOLISM IN ELDERLY: THE ER AS A WINDOW ON REAL LIFE

Purpose

Assess which vital parameters or shock parameters, in the real life of an Emergency Department, correlate with the presence of massive pulmonary embolism to see which ones can be of help to early suspect it.

Methods

Single–center retrospective observational study, on all geriatric patients (> 75 y) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Anni), and for the presentation of the risk of mortality at 30 days (sPESI). We then had all chest CTs retested by an experienced radiologist. We assess the correlation of vital parameters and shock indexes with the presence of massive pulmonary embolism. We took into consideration: the shock index (SI), the modified shock index (MSI) and the age–shock index (AGE_SI).

Results

We enrolled 247 patients, with a mean age of 83 years and prevalence of female (F = 63%). Of these, 85 (34.4 %) presented with massive pulmonary embolism. There is no correlation between blood pressure, systolic and diastolic values, respiratory rate with the presence of massive pulmonary embolism (p > 0.05). However, there is a strong statistical correlation between heart rate values and the presence of massive pulmonary embolism (p < 0.0001). The shock index correlates with the presence of massive pulmonary embolism with good statistical strength (p < 0.001); the modified shock index correlates with the with even greater statistical strength (P = 0.0005). The age–shock index correlates with the presence of pulmonary embolism with excellent statistical strength (p < 0.0001).

Conclusions

The study suggests that the alteration of shock indices, in particular of the AGE–shock index, correlate with the condition of massive pulmonary embolism. Taking into consideration these parameters, of very low cost, available from triage and obtainable in a few minutes at the medical examination, easily performed in the various Italian situations, can help to raise the suspicion of massive pulmonary embolism early and direct the patient more quickly towards the correct procedure therapeutic diagnostic.

P275 HOLDING AREA IN EMERGENCY DEPARTMENT : A STRATEGY TO IMPROVE ADHERENCE TO INTERNATIONAL GUIDELINES IN CASES OF PULMONARY EMBOLISM IN ELDERLY

Premises

Pulmonary embolism is a disease still characterized by high mortality. Despite a great development of the guidelines it is not clear what adherence to them is in real life, especially in the emergency room.

Purpose of the Study

See if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the area to which the patient is addressed.

Methods

Monocentric retrospective observational study, on a group of geriatric patients (<75 y) that include all the people accessed to our ED, where they received acute PE dignosis. Enrolment started on 2016 and finished on 2019. We collected data from medical history, physical examination, lab tests, imaging; we calculated characteristic scores from the diagostic/therapeutic algorhitm, both regarding PE risk (Wells, Geneva and Years), and the 30–day mortality risk presentazione (sPESI). We then analized guidelines adherence in three decision–making turning–points: 1 Correct applicarion of decisional scores examined, which classify the patient in low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct therapy administration since the ED as suggested by the guidelines; 3 The eventual observation in the medium–intensity care area with close monitoring for the subpopulation of patients with finding of right ventricular dilation or myocardial enzymes impairement (considered at high risk of short–term shock and mortality).

Results

we enrolled 249 patients, with a mean age of 83 years and female prevalence (F = 62%). Of these, 69% were referred by Triage to medium–high intensity of care, the remaining 31% was directed to low intensity of care. 42.5% of the total patients were referred to OBI. The two areas of intensity of care showed similar adherence to guidelines (approximately 50%) without there being a statistically significant difference between the two areas (p > 0.05) Adherence to guidelines was higher in the holding area – OBI (75 %) compared to that of those managed in theaters (50%) in a statistically significant way (p < 0.001).

Conclusions

The study suggests that holding areas located in Emergency Departments can considerably increase adherence to international guidelines.

P271 DOES SENILITY AFFECT THE MANIFESTATION AND MANAGEMENT OF PULMONARY EMBOLISM? EXPERIENCE OF AN ED

Premises

Acute pulmonary embolism is a pathology characterized by high mortality. The elderly population is destined to increase, becoming, according to some authors, 30% of the population in the developed countries.

Purpose of the Study

see if and how, in the real life of an Emergency Department, age can affect the manifestation (more severe or milder forms of pulmonary embolism; typical symptoms and atypical symptoms), patient management and adherence to guidelines. We considered subjects over 75 years of age to be elderly, as per the latest indications of the guidelines.

Methods

Single–center retrospective observational study on all patients who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We analyzed the hospitalization rate, in–hospital mortality rate, the hospitalization rate in resuscitation and the length of hospitalization. We then analyzed adherence to the guidelines valid in the period under study.

Results

We enrolled 487 patients, with equal gender distribution (F = 52%). 247 were older than 75 (50.7%). Age has a positive correlation with the presence of massive pulmonary embolism, in a statistically significant way (p < 0.05), and with the presence of organ damage, touching on statistical significance (p = 0.05). On the other hand there is no statistically significant difference in the prevalence of typical or atypical symptoms in the two groups. The vital parameters were instead comparable in the two groups with no statistically significant difference (p > 0.05). Long–term outcomes such as mortality, need for hospitalization, ICU stay and length of stay in hospital are also comparable results without statistically significant difference (p > 0.05). Adherence to international guidelines is also comparable between the two groups (p > 0.05).

Conclusions

The study suggests that age correlates with more severe forms of pulmonary embolism but does not affect either patient management or short–term outcomes.

P265 RED ZONE: 22 MILES OF FIRE. ANALYSIS OF THE TIMING AND PROCESSES OF ELDERLY PATIENTS WITH ACUTE PULMONARY EMBOLISM IN THE EMERGENCY ROOM. THE REAL–LIFE EXPERIENCE OF 5 YEARS IN THE EMERGENCY ROOM

Purpose

to describe the role of the emergency room in the diagnostic–therapeutic process of acute pulmonary embolism.

Methods

single–center retrospective observational study, on all geriatric patients (> 75 years) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We analyzed means of presentation, priority codes for medical examination, exit code, hospitalization needs. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes.

Results

We enrolled 247 patients, all requiring hospitalization for acute pulmonary embolism. The average age of 83 with female prevalence (63%). Median wait times for medical examination were 42 minutes. The average waiting times, however, for the large number of low priority codes (40% between 5 and 4 codes), was more than 6 hours. All patients required a chest CT with contrast, 44% first did a chest x–ray and 2% an ultrasound. All patients underwent ECG and blood tests. The time spent in the Emergency Department (LOS) was on average 18 hours. 58% of patients were managed in areas of low or medium intensity, 42% were sent to OBI for therapeutic diagnostic completion or necessary monitoring. OBI patients were on average 504 minutes. 56% face the phenomenon of boarding. 34% showed massive EP, 32% showed organ damage. 41% were considered to be at high risk of short–term mortality according to European guidelines, 8% required intensive care and in–hospital mortality was 7.7%. Under triage is 31%.

Conclusions

The population that arrives in ED due to pulmonary embolism presents an overall clinical picture with a high degree and high care and therapeutic complexity. Need for numerous investigations and second level imaging. They often require complex therapies and multi–parameter monitoring during stabilization and observation. Therefore, the time spent in the emergency room is long. The workload to treat these patients is high and requires excellent multi–professional and multidisciplinary integration, especially between the various professional figures in urgency, the laboratory and radiology.

P341 DANTE (DIAGNOSTIC ACUTE PATIENT TOOL IN EMERGENCY) & BEATRICE (BEDSIDE ECHOCARDIOGRAPHIC ASSESMENT FOR IMPROVE CLINICAL EVALUATION) FOR GERIATRIC PATIENTS

Objectives

To determine whether comprehensive quantitative bed side echocardiogram could be used as a usual assessment tool in acute geriatric patients and to assess its effect on patient care.

Design

Retrospective. Setting: DEA di II livello IRCSS Policlinico san Matteo.

Patients

Acute ill medical, trauma and surgical patients. A doctor enrolled in the discipline of emergency medicine was assigned to perform bedside echocardiograms of acute inpatients. This work took only geriatric patients into consideration. (> 65aa). Interventions: The Bedside Echocardiographic AssesmenT foR Improve Clinical Evaluetion (BEATRICE), a comprehensive transthoracic echocardiogram was performed.

Measurements and Main Results

6–month period, 369 BEATRICEs were performed. The mean patient age was 76.2 (±14.3) years. 95% were hospitalized in medical departments and 5% in surgical ward. In 97.4% of cases BEATRICE was performed in a timely manner. The ejection fraction, cardiac index and the volumetric indices of the left ventricle is reported in 97% of the reports. Estimated stroke volume, longitudinal systolic function with tissue Doppler and atrium study is reported in 99.7%, 98.6% and 98.9% of BEATRICE studies. The study of diastolic and atrium function is reported in 99.3% and 98.9% of the reports respectively. Estimated left ventricular filling pressures are reported in 98.3% of the measurements. Information on the vena cava reported for 98%. Right heart function was assessed for 91.8%. Mean or systolic right ventricular pressures, or both, were also estimated in 91.9% of the reports. The BEATRICE was judged to be useful by the consulting primary care team in over 96% of cases, BEATRICEs allow the modification of therapy or the diagnostic process in over 40% of cases (in 27% of cases they allow to significantly modify the therapy and in 16% of cases they allow to significantly modify the diagnostic therapeutic procedure) and speeding up the diagnostic process in over 30% of cases.

Conclusions

The BEATRICE is feasible and alters care in the intensive care unit by providing clinical data not otherwise available at the bedside. Further studies are warranted to assess the impact of comprehensive echocardiogram–directed resuscitation on patient outcomes.

P267 EFFECTIVENESS OF SHOCK INDICES AND ALTERATION OF VITAL PARAMETERS IN THE DIAGNOSTIC SUSPICION OF ORGAN DAMAGE FROM PULMONARY EMBOLISM IN ELDERLY: THE EMERGENCY ROOM AS A WINDOW ON REAL LIFE

Aim

Assess which vital parameters and shock indices correlate with the presence of organ damage from pulmonary embolism to see which ones can help to suspect this condition early.

Methods

Single–center retrospective observational study, on all geriatric patients (> 75 y) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic/therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We then had all chest CTs retested by an experienced radiologist. We went to see the correlation of vital parameters and shock indexes from these derivatives with the presence of organ damage from pulmonary embolism. We considered right ventricular dilation, pulmonary artery dilation and the presence of pulmonary infarction organ damage. We have considered as shock indices: the shock index (SI), the modified shock index (MSI) and the age–shock index (AGE_SI).

Results

We enrolled 247 patients, with a mean age of 83 years and prevalence of female (F = 63%). Of these 79 (32%) have organ damage from pulmonary embolism. There is no correlation between the values of blood pressure, systolic and diastolic, respiratory rate with the presence of organ damage (p > 0.05). However, there is a strong statistical correlation between heart rate values and the presence of organ damage from pulmonary embolism (p < 0.001) The shock index correlates with the presence of organ damage with good statistical strength (p < 0.001 ); also the modified shock index, albeit with a slightly lower statistical strength (P < 0.005). The age–shock index correlates with the presence of pulmonary embolism with excellent statistical strength (p < 0.001).

Conclusions

The alteration of the shock indices, in particular the AGE–shock index, correlate with the condition of organ damage. Taking into consideration these parameters, of very low cost, available from triage and obtainable in a few minutes at the medical examination, which can be easily performed in the various Italian situations, can help to raise the suspicion of organ damage from pulmonary embolism early and address more quickly the patient towards the therapeutic diagnostic process.

P264 ROLE OF BLOOD GAS ANALYSIS AND D–DIMER IN RAISING THE SUSPICION OF MASSIVE PULMONARY EMBOLISM IN GERIATRIC PEOPLE: THE EMERGENCY ROOM AS A WINDOW INTO REAL LIFE

Premise

Massive pulmonary embolism is burdened with high mortality. Raising suspicion and recognizing this condition early allows to avoid delays in the diagnostic and therapeutic process.

Purpose

Assess which parameters of blood gas analysis, in the real life of an Emergency Department, correlate with the presence of massive pulmonary embolism to see which ones can help to suspect it early.

Methods

single–center retrospective observational study, on all geriatric patients (> 75 y) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We looked at all the blood gas analyzes performed at the emergency room access. We then had all chest CTs retested by an experienced radiologist.

Results

We enrolled 247 patients, with a mean age of 83 years with prevalence of female prevalence (F = 63%). Of these, 85 (34.4%) have massive pulmonary embolism. Lactates do not correlate with the presence of massive pulmonary embolism (p > 0.05). The pCO2 values correlate inversely with the presence of massive pulmonary embolism with excellent statistical strength (p < 0.0001). The reduction in pO2 values also correlates with the presence of massive pulmonary embolism, with good statistical strength (p < 0.005). The increase in pH values also correlates with the presence of massive pulmonary embolism, albeit with a lower statistical strength (p < 0.05). The D–Dimer shows a strong association with massive pulmonary embolism values (p < 0.0001).

Conclusions

The study suggests that the reduction of pCO2 values, with an increase in pH and D–Dimer show a strong correlation with the condition of massive pulmonary embolism. Similarly, the pO2 can play a role in the identification of this condition, while no role would seem to have the alteration of lactates. Taking into consideration these parameters, which are quickly available and easily performed in the various Italian situations, can help to raise the suspicion of massive pulmonary embolism early and direct the patient more quickly towards the therapeutic diagnostic process.

P273 MANAGEMENT OF ACUTE PULMONARY EMBOLISM IN GERIATRIC PATIENTS IN THE EMERGENCY ROOM: DOES ADHERENCE TO INTERNATIONAL GUIDELINES REDUCE IN ATYPICAL SYMPTOMS?

Purpose of the Study

Evaluate if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the presence of atypical symptoms. We understood dyspnoea, chest pain, signs and symptoms of deep vein thrombosis and syncope as typical symptoms. As atypical symptoms all the others (low–grade fever, vertigo …)

Methods

Single–center retrospective observational study on all geriatric patients (>75 y) who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic/therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We then analyzed adherence to the guidelines in three decision turning points: 1 Correct application of the decision scores examined, which classify the patient at low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct administration of therapy starting from ED as suggested by the guidelines; 3 Any observation in the care area of medium intensity with careful monitoring for the subpopulation of patients with evidence of right ventricular dilation or myocardial enzyme elevation (considered to be at high risk of shock and short–term mortality).

Results

We enrolled 248 patients, with a mean age of 83 years with female prevalence (F = 63%). Of these, only 17 with atypical symptoms and 231 with typical symptoms. The vital signs were comparable in the two groups with no statistically significant difference (p > 0.05). Long–term outcomes such as mortality, need for hospitalization, hospitalization in intensive care and length of stay in hospital are also comparable results with no statistically significant difference (p > 0.05). However, adherence to international guidelines was statistically significantly lower in patients with atypical symptoms (33%) than in patients with typical symptoms (59%) (p < 0.05).

Conclusions

The study suggests that patients with atypical symptoms are more likely to have reduced adherence to international guidelines, most likely due to diagnostic delay.

P274 GUESS WHO‘S COMING TO REANIMATION? ANALYSIS OF THE ELDERLY PATIENT WITH EMBOLISM IN NEED OF HOSPITALIZATION IN INTENSIVE CARE: REAL LIFE IN THE EMERGENCY ROOM

Premise

Pulmonary embolism is a disease still characterized by high mortality and which may require hospitalization in intensive care.

Purpose

Evaluate which parameters, in the real life of an Emergency Department, correlate with the need and the duration of hospitalization in intensive care.

Methods

Single–center retrospective observational study, on all geriatric patients (> 75) who refer to our ED, where they were diagnosed with acute PE. Enrollment began in 2015 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes.

Results

We enrolled 247 patients, with a mean age of 83 years and female prevalence (F = 63%). Of these 12 (14 %) required hospitalization in intensive care from the emergency room. Regarding the need for hospitalization in resuscitation, age and vital parameters (arterial pressure, respiratory rate, heart rate), as well as derived shock indices are not correlated (p > 0.05). Only the systolic blood pressure values and it show a trend which however does not reach statistical significance (p = 0.06). Among the blood gas analysis parameters, only low pCO2 has a slight correlation (p < 0.05). The D–Dimer (p < 0.01) and creatinine values (p < 0.05) show correlation between the blood chemistry tests. Regarding the length of stay in resuscitation, age and vital parameters (blood pressure, respiratory rate, heart rate), as well as derived shock indices, do not show any correlation (rho∼0; p > 0.05). A weak correlation is instead present with high values of D–Dimer (rho∼0.25; p < 0.005) and creatinine (rho∼0.33; p < 0.0005). The presence of massive pulmonary embolism shows no correlation (p > 0.5). The presence of organ damage, on the other hand, correlates in a statistically significant manner (p < 0.0005). Excellent correlation is shown by the sPESI index (p < 0.0001). Discrete correlation showed the alteration in pH (rho∼0.61; p < 0.0001). Correlation for the blood gas analysis parameters taken into consideration (pH; pO2; pCO2; lactates).

Conclusions

The study suggests a reduced significance of vital parameters and indices derived from them for the need and duration of hospitalization in resuscitation. Presence of organ damage, low pCO2 values and high D–Dimer and creatinine values are associated with both the need for hospitalization in resuscitation and duration.

P268 MANAGEMENT OF ACUTE PULMONARY EMBOLISM IN THE EMERGENCY ROOM IN ELDERLY: DOES ADHERENCE TO INTERNATIONAL GUIDELINES INCREASE IN THE MOST SERIOUS CASES?

Premises

Pulmonary embolism is a pathology still characterized by high mortality. Some international studies have actually shown that adherence to guidelines is generally quite low in both primary and secondary care and ranges, depending on the studies, between 40 and 60%.

Purpose of the Study

see if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the severity of the acute pulmonary embolism. We understood this severity as the presence of organ damage or massive pulmonary embolism.

Methods

Single–center retrospective observational study, on all geriatric patients (>75 y) who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We therefore analyzed adherence to the guidelines in three decisional turning points: 1 Correct application of the decision scores examined, which classify the patient at low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct administration of therapy starting from ED as suggested by the guidelines; 3 Any observation in the care area of medium intensity with careful monitoring for the subpopulation of patients with finding of right ventricular dilation or myocardial enzyme elevation (considered to be at high risk of shock and short–term mortality).

Results

We enrolled 248 patients, with a mean age of 83 years with female prevalence (F = 62%). Of these, 81 (32.7%) have organ damage and 86 (34.7%) have massive pulmonary embolism. Patients with organ damage received treatment with a higher adherence to the guidelines (68%) than those who did not have organ damage (51%) in a statistically significant way (p < 0.01). Patients with massive pulmonary embolism received treatment with a higher adherence to the guidelines (69 %) than those with peripheral pulmonary embolism (50%) in a statistically significant way (p < 0.005).

Conclusions

The study suggests that patients with organ damage or massive pulmonary embolism are more likely to receive treatment in the emergency room with greater compliance with international guidelines.

[Topical interest of the origin of Hygiene and Public Health]

Potrebbe destare stupore richiamare l'attenzione dei cultori dell'Igiene e Sanità pubblica su una tra le opere più significative delle circa settanta che costituiscono il Corpus ippocratico - probabilmente assemblato nella biblioteca di Alessandria, all'inizio del III secolo a.C. - cioè sull' "Aria, Acqua, Luoghi", che identifica nell'ambiente, nelle condizioni metereologiche, nelle sostanze presenti nell'acqua da bere e in altri fattori molto concreti le possibili cause delle malattie, anziché attribuire loro un'origine soprannaturale. Questa intuizione millenaria attribuita ad Ippocrate, padre della Scienza medica, ha improntato tutta la storia dell'Igiene e Sanità pubblica dando luogo ad un immenso corpus dottrinale che, seguendo man mano le nuove conoscenze, ha dimostrato la natura dinamica e il continuo ampliamento della disciplina. Disciplina che sta ora sempre più interessando il mondo non solo scientifico ma anche politico e popolare impressionato dalla manifestazione di vistosi fenomeni naturali attribuibili ad una modificazione di equilibri tra i componenti dei tre regni della natura: animale, vegetale e minerale.

[The "redisorganisation" of the Italian Healthcare Service]

Non vi è alcun dubbio che, sotto la spinta degli effetti sanitari della pandemia da COVID19 e della approvazione (il 13/7/2021) del Piano Nazionale di Ripresa e Resilienza (PNRR), si è in presenza ancora una volta di un tentativo di riorganizzazione del Servizio sanitario nazionale. Alcuni significativi elementi di questa volontà politica sono stati già indicati negli Editoriali di questa Rivista pubblicati negli ultimi due anni - dalla dichiarazione dello stato di emergenza nazionale per il contenimento della diffusione dell'epidemia da COVID-19 (D.L. 25/3/2020, n. 19) a tutt'oggi. Gli esperti diScienze politiche applicate alla sanità hanno fatto rilevare che le proposte di riorganizzazione - soprattutto tendenti a rafforzare la sanità territoriale (cure primarie e servizi territoriali)2 - risalgono addirittura alla legge istitutiva del Servizio sanitario nazionale e sono state "rinnovellate"da numerosi successivi atti legislativi mai completamente realizzati. La motivazione è facile da comprendere perché da tempo è fin troppo noto che non è possibile modificare un sistema, come quello sanitario (ma non solo questo), unicamente attraverso cambiamenti strutturali3. Una riforma per avere successo deve innescare un'interazione virtuosa tra il dispositivo normativo e il sistema sociale di realizzazione, composto dagli esecutori e dai beneficiari della riforma. L'antica metafora botanica della semina può rendere l'idea: anche la migliore semenza non può attecchire su un terreno arido o poco soleggiato e se le radici non trovano nel suolo il necessario alla crescita della pianta.

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La recente approvazione del testo unico sulle malattie rare da parte dei due rami del Parlamento (Disposizioni per la cura delle malattie rare e per il sostegno della ricerca e della produzione dei farmaci orfani) richiama l'attenzione degli operatori di Sanità pubblica su una materia vasta e disomogenea come la ricerca, la diagnosi e il trattamento delle malattie rare. La disponibilità di un testo di legge, anche se devono seguire i decreti attuativi per rispondere alle necessità concrete dei malati e delle loro famiglie, è comunque uno strumento essenziale nella "cassetta degli attrezzi" degli operatori in quanto «dai documenti storici più antichi a quelli contemporanei si hanno prove del ricorso ad atti normativi non solo nei momenti di emergenza (gestione delle epidemie) ma anche nell'organizzazione e il controllo della vita quotidiana sempre in nome e per conto della salute collettiva» (Editoriale. La normazione, lo strumento cardine di Sanità pubblica. Igiene e Sanità Pubblica 2020; 76: 284-286).

[Community Medicine revival. Community Medicine (revised and corrected)]

A "la Scienza e l'Arte di prevenire le malattie, di prolungare la vita e di promuovere la salute attraverso gli sforzi organizzati della società" sono stati attribuiti molti nomi, variamente associati tra loro: Sanità pubblica, termine onnicomprensivo della multidisciplinarietà della materia, ma anche Igiene, Medicina preventiva, Medicina sociale, Medicina di comunità a seconda del prevalente campo di attività messo in atto. L'inserimento della dimensione comunitaria nella teoria e nella pratica della Medicina richiede però la definizione di comunità, il coinvolgimento nell'azione di tutela della salute (promozione, conservazione e recupero), la localizzazione territoriale (dove la gente vive e lavora), la disponibilità di risorse finalizzate e così via. Una esigenza quanto mai necessaria specialmente ora che l'ormai "mitico" Recovery Plan - ovvero Piano Nazionale di Ripresa e Resilienza (PNRR) - cita ripetutamente la"Comunità" facendone un elemento di rilievo dell'azione progettuale. Uno degli interventi previsti è infatti la realizzazione entro il 2026 di 1.288 Case della Comunità. Queste sono ideate come strutture sanitarie, promotrici di un modello di intervento multidisciplinare, nonché luoghi privilegiati per la progettazione di interventi di carattere sociale e di integrazione sociosanitaria esprimendo una nuova modalità di presa in carico delle persone e delle comunità per prevenire le malattie, prolungare la vita e promuovere la salute. Ne consegue che la sede della Casa della Comunità deve essere visibile e facilmente accessibile per la comunità di riferimento (struttura di prossimità) perché è il luogo dove il cittadino può trovare una risposta adeguata alle più diverse esigenze sanitarie o sociosanitarie. La soluzione organizzativa raccomandata (in informatica "hub & spoke") prevede un elemento centrale di una rete per le cure primarie e per i supporti sociali e assistenziali, proponendosi come luogo di offerta, ma contestualmente come luogo di relazione e di attenzione a tutte le dimensioni di vita della persona e della comunità.

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A credere nell'Astrologia la pandemia da COVID-19 poteva essere agevolmente prevista in quanto era già scritta nelle stelle (per la congiunzione di Saturno e Plutone in Capricorno!!!)1. Ma de-sideri e con-siderazioni riprendono etimologicamente il termine latino sidus, sideris (plurale sidera). "De-siderare", composto dalla particella privativa "de-" significherebbe, letteralmente, condizione in cui sono assenti le stelle e quindi le loro influenze e i loro presagi. "Con-siderare" è il suo naturale opposto al positivo, ovvero parafrasando "stare con le stelle", in condizioni cioè di prevedere e giudicare. L'assenza di "stelle" - ovvero di punti di riferimento (nautici) - produce insicurezza e suscita voglia di orientamento; considerare è il termine abusato con cui inizia ogni atto legislativo per elencare i riferimenti che motivano la decisione (pur affidandosi etimologicamente alla sorte).

[More on the COVID 19 pandemic: Public health Apology]

La pandemia da COVID 19 sembra somigliare sempre più ad un "buco nero galattico" in cui vengono inghiottite tutte le energie e tutti i pensieri dell'intera comunità nazionale. Quest'ultima, al pari di un drogato, sembra attendere ansiosamente la quotidiana "dose" di notizie, in una condizione, cioè, di trovarsi gradualmente a non poter controllare il desiderio di assumere una certa sostanza nonostante il danno fisico, psicologico, affettivo, emotivo o sociale che può conseguire a tale assunzione.

[Florence Nightingale and the SARS-CoV-2 coronavirus pandemic]

Per la Sanità pubblica l'anno 2020 appena trascorso si può rappresentare con due avvenimenti: la grande pandemia da coronavirus SARS-CoV-2 (così chiamato per la sua immagine circondata da "spine") e il bicentenario della nascita di Florence Nightingale (così chiamata perché nata a Firenze il 12 maggio 1820). L'abbinamento di questi due avvenimenti è meno lontano di quanto sembri prestandosi ad alcune istruttive considerazioni.

[A Public Health topic: the health (di/smis) information]

La parola italiana "disinformazione" abbraccia i due termini inglesi di "disinformation" e "misinformation" avvalorando la maggiore precisione terminologica della lingua anglosassone. Il primo inteso come informazioni infondate che non sono intenzionalmente false ma credute vere. La storia della Medicina non è altro che la cronaca di un susseguirsi di disinformazioni corrette progressivamente nel tempo mano a mano che venivano acquisite nuove conoscenze, Il secondo termine indica invece informazioni intenzionalmente false o fuorvianti, diffuse con qualche intento, di norma per ottenere vantaggi politici, economici, o elogiativi.

[Public Health commitment to the protection of health at the time of the pandemic]

Non è il caso di ricordare che la Sanità pubblica è nata e si è sviluppata per tutelare la salute "come fondamentale diritto dell'individuo e interesse della collettività". Certamente l'attuale "Ab occulta coeli influentia"2 da Coronavirus SARS-CoV-2 o COVID-19 ha messo a dura prova la tutela della salute da parte della struttura e organizzazione della Sanità pubblica.3.

Multidisciplinary model for hospital-territory integrated management of patient with bone fragility: primary and secondary prevention of fractures according to severity and complexity

The aim of this study was to promote the construction of a real network and a shared diagnostic and therapeutic management model between hospitals and out-of-hospital healthcare services to capture as many patients with bone fragility as possible. Starting from the analysis of the clinical competences present in the province of Pavia, the bone specialists (BSs) organized some educational events involving both general practitioners (GPs) and hospital specialists. The Fracture Liaison Service (FLS) model, the revision of Note 79, the national plan for chronicity and the health reform of the Lombardy Regional Authority supported the structure of our model, in which the roles of clinicians are well defined and based on the complexity and severity of patients. In our method the GP has a central role as clinical manager, facilitating patient management and communication between the specialists and the BS. In January 2019, the Therapeutic Care Diagnostic Path (PDTA) shared between 2 bone specialists (BSs), 9 GPs, as reference treaters, and a multidisciplinary group of 25 specialists of the Province of Pavia was defined. The strategic directions of the two largest public hospitals in Pavia have supported the PDTA, which was validated by the quality departments of the hospitals themselves. Finally, sixty GPs belonging to the network have joined the PDTA. This model is the first example of integrated management between hospitals and out-of-hospital healthcare services for the primary and secondary prevention of fragility fractures (FF), where the GPs play a pivotal role as managers and supervisors to ensure proper care to chronic patients according to their levels of severity.

Prevention of nosocomial legionellosis by best water management: comparison of three decontamination methods

BACKGROUND

Since 2000, the National Health System has adopted international guidelines for assessing Legionella spp. in hospital water systems. The control of water contamination by Legionella spp. is still a matter of research concerning the most effective method in preventing nosocomial infections.

AIM

To compare three different decontamination methods by monitoring colony-forming unit count and number of hospital-acquired legionellosis cases. A secondary objective was to evaluate the long-term effects of the preventive measures on the water pipes.

METHODS

A protocol was developed for the selection of high-risk sampling sites and for the testing of three disinfection methods over the course of 19 years: hyperchlorination and thermal shock (period A, 2000-2005); copper-silver ionization (period B, 2006-2010); and integration of pre-filtering, filtering, pipe-protecting products, and remote control with chlorine dioxide (ClO₂) (period C, 2011-2018).

FINDINGS

The use of shock disinfection and hyperchlorination led to a decrease in contamination level immediately after the procedure, but then it rose again to the previous level in two months. Both copper-silver ionization and ClO₂ disinfection showed a stable and durable decrease in contamination level. Throughout these three phases, six cases of Legionella spp. occurred during period A, six cases during period B, and three cases during period C. With regard to the damage of water pipes, effective copper-silver levels caused corrosion and calcification in water pipes.

CONCLUSION

Both copper-silver ionization and ClO₂ properly controlled Legionella spp. contamination. ClO₂ significantly reduced the number of positive sites (P < 0.001) without damaging the pipelines.

Public Health and Hospitals: a Common Area for Clinical and Public Health Medicine

Contrary to what has happened so far, hospitals should become a setting which jointly exercise Clinical and Public Health Medicine. The areas of activity that require the presence of multidisciplinary teams and can bring benefits both to the patients and to the community is briefly described.