[Clinical pathways for the care of multiple sclerosis patients]

INTRODUCTION

clinical pathways are standard health care methods to coordinate clinical work, reduce inter-clinician variability, improve patient care and increase staff and patient satisfaction. The aim of this study is to develop a clinical pathway capable of organising and developing standard procedures for diagnosis, treatment and care in patients with multiple sclerosis and to coordinate all medical specialists involved in this disease.

METHODS

a multidisciplinary unit for the care of MS patients was developed. All of them and quality specialists analysed some international evidence-based studies, clinical guides, international guidelines and other clinical neurological pathways in several meetings and designed several documents for the clinical pathways.

RESULTS

a clinical pathway was created consisting of a scientific-technical framework, which arranges the care in relation to the diagnosis and reatment. The framework is accompanied by various patient-information documents on the disease, an information sheet on diagnostic procedures and a map of the process. Quality standards were established to achieve continuous improvement in patient care.

CONCLUSIONS

a clinical pathway for the care of MS patients in a multidisciplinary unit homogenises and organises the care which the MSpatient should receive from the initial symptoms to the progressive stages. This clinical pathway improves the quality of patient care, reduces the variability in work protocols and rationalises the use of the available health care resources.

[Development of an acute stroke care pathway in a hospital with stroke unit]

INTRODUCTION

Care pathways (CP) are tools for standardizing the management of patient in certain diseases with a predictable course, and they have demonstrated usefulness in clinical practice. In-hospital stroke CP have been implemented in departments of Neurology, General Medicine or Rehabilitation, however there are few studies developing an integrated CP in hospitals with an acute Stroke Unit (SU). The aim is to develop a CP capable of organizing and homogenizing the stroke assistance, and integrating the quality standards, in a hospital with an Acute Stroke Unit (SU).

METHODS

Members of the Neurology, Rehabilitation, Emergency and Preventive Medicine departments established a schedule of nine fortnightly meetings. Several documents that compound the CP were elaborated following the FOCUS-PDCA model, according with the scientific evidence and the in force clinical guides.

RESULTS

The following documents were elaborated: scientific-technical framework which integrates all processes; information document for patient/relatives on-admission; nurses protocols (social risk, disphagya, falling down risk and pressure ulcers); stroke rehabilitation guidelines for staff; treatment, care and monitoring sheets; recommendations at discharge for patient/relatives; stroke rehabilitation guidelines for patient/relatives; specific didactic units for patient/relatives; patient/relatives satisfaction survey; and quality standard document.

CONCLUSIONS

A stroke CP in a hospital with SU potentially promotes a more organized and efficient stroke care, as well as improve the patient/relatives satisfaction.

Emergence of CTX-M-15-producing Klebsiella pneumoniae of multilocus sequence types 1, 11, 14, 17, 20, 35 and 36 as pathogens and colonizers in newborns and adults

OBJECTIVES

To characterize the population structure and resistance mechanisms of Klebsiella pneumoniae isolates that are highly resistant to third-generation cephalosporins, collected from five Spanish hospitals.

METHODS

A total of 162 K. pneumoniae isolates from five hospitals located in three geographical areas of Spain were characterized. The number of isolates from each hospital ranged from 3 to 82. The genetic relationship between isolates was established by PFGE and multilocus sequence typing (MLST). bla(ESBL) types and other antibiotic resistance genes were analysed by PCR and sequencing. Plasmids were classified according to their incompatibility group by a PCR-based replicon-typing scheme.

RESULTS

All 162 isolates carried the bla(CTX-15) gene. Fifty-eight isolates (35.8%) caused clinical infections and 104 (64.2%) were colonizers. Sixty-nine (42.6%) isolates were collected from newborns and 93 (57.4%) from adults. Using PGFE, the 162 isolates were grouped into seven clusters that were further identified as members of the MLST types 1, 11, 14, 17, 20, 35 and 36. Two hospitals each had two different clones and the remaining three hospitals had a single CTX-M-15-producing K. pneumoniae clone. All clones carried different antibiotic resistance genes, including bla(OXA-1), aac(3)-IIa, aac(6')-Ib-cr, qnrS1 and qnrB. In four of the seven (57.1%) clones the bla(CTX-M-15) gene was transferred by conjugation; in all cases plasmids of the incompatibility group IncF were identified by PCR.

CONCLUSIONS

This study shows that multiresistant K. pneumoniae producing CTX-M-15 of MLST types 1, 11, 14, 17, 20, 35 and 36 are spreading as pathogens and colonizers among newborns and adult patients in Spain.

[Impact of cataract surgery on visual acuity and quality of life]

OBJECTIVE

To evaluate visual acuity and quality of life improvement after cataract surgery.

METHODS

Visual acuity and quality of life were assessed in patients undergoing phaco-emulsification. They were of both genders, ranged from forty-six to ninety-two years of age, and were able to understand the SF-36 quality of life questionnaire which explores the differences in quality of life before and after surgery. The questionnaire was completed before cataract surgery and again 6 and 18 months later. Visual acuity was measured with Snellen optotype.

RESULTS

The answers of 150 patients were evaluated in this study. The average age was 74.32 years. After the surgery the body pain results increased, with this shown to be statistically significant. The social function, general health, perception, role limitation due to physical problems and physical function significantly improved between the first and third consultations. There were no significant differences in role limitation due to emotional problems, nor in vitality. The mental health dimension became worse between consultations although there was no statistically significant difference found. The average values for Visual Acuity were 18.39, 66.01 and 69.02 at the three timed assessments made.

CONCLUSIONS

Cataract surgery performed by phacoemulsification has been proven to be effective in improving quality of life, especially in physical aspects, according to the improvement in role limitation due to physical problems. Visual acuity also improves after surgery. Disease specific instruments, such as the SF-36, should be used as the outcome measure in clinical practice after cataract surgery.

[Development of a clinical pathway for the attention of patients with amyotrophic lateral sclerosis in a regional network. ALS Assistance Network-Comunidad de Madrid]

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) requires complex multidisciplinary attention. Clinical pathways are assistance plans for certain diseases with a predictable course. These plans are established in isolated centers, not in multicenter regions. The aim is to develop a clinical pathway capable of organizing and homogenizing assistance given in ALS Assistance Network-Comunidad de Madrid which is made up of five hospitals, from the beginning until the end of the disease.

METHODS

In successive meetings, neurologists of these hospitals and members of the Madrid Health Service evaluated published therapeutic guidelines and other documents used in ALS assistance. A clinical pathway was developed adapting this information to social-health care conditions in the Comunidad de Madrid following the FOCUS-PDCA model.

RESULTS

A clinical pathway was created consisting of a scientist-technical framework which arranges the attention in relationship to the diagnosis and treatment, according to the degree of disease progression and a chronogram. This is accompanied by several patient information documents on the disease and the tests that are required, and a patient assistance evaluation form. The standards are established to reach and to promote 354 constant improvement in patient care.

CONCLUSIONS

Clinical pathway for the ALS assistance in a regional network organizes the attention and cares that the patients must receive from the beginning to the end of the disease. This arrangement and homogenization of the attention improves the quality of patient care, diminishes variability and rationalizes the use of the health care resources.

[Nosocomial outbreak of epidemic keratoconjunctivitis in a neonatal intensive care unit]

OBJECTIVE

To describe an epidemic nosocomial outbreak of keratoconjunctivitis affecting at least 43 people in a Neonatal Intensive Care Unit in Madrid, between May and October 2002, perform epidemiologic research and determine preventive measures to prevent new outbreaks.

METHODS

Description of the outbreak, clinical case definition, microbiologic and epidemiologic research through the use of questionnaires. Analysis of the incidence of subepithelial infiltrates 1 year after infection and the use of topical corticosteroid therapy.

RESULTS

The epidemic began in the Neonatal Service, with a pair of twins being found as the initial focus. Dissemination occurred to about 24 workers of the unit, and 19 workers from other services. The microbiologic diagnosis confirmed adenovirus in 10 conjunctival smears and one serologically, with the remainder obeying clinical and epidemiological criteria of such infection. Infected patients using topical corticosteroids had a higher incidence of infiltrates 12 months later than those not using such agents (p=0.003 in Fisher test).

CONCLUSIONS

Epidemic keratoconjunctivitis occurs frequently, is highly contagious and has possible long-term sequelae, necessitating the use of preventive measures to avoid spread and new outbreaks.

Nosocomial and community-acquired meticillin-resistant Staphylococcus aureus infections in hospitalized patients (Spain, 1993–2003)

A series of annual surveys on the prevalence of infections in hospitalized patients in Spain was undertaken from 1993 to 2003 to describe clinical and demographic characteristics, trends and geographical variations in the proportion of meticillin-resistant Staphylococcus aureus (MRSA). A total of 8312 S. aureus infections in patients from 296 acute care hospitals pertaining to 17 regions in Spain were observed during the study period. Overall, 23.8% of these organisms were reported as meticillin resistant. The proportion of MRSA varied widely across regions and during the study period. Patients with nosocomial infections (NIs) had a two-fold higher prevalence of MRSA (31%) than patients with community-acquired infections (CAIs) (14%; P<0.001). Nevertheless, there was an increasing trend in the prevalence of MRSA isolates, both in patients with NI (from 22% to 41%; P<0.001) and with CAI (from 7% to 28%; P<0.001) throughout the 11-year period. Geographical variations over the last three years (2001-2003) show a centripetal gradient, with the lowest MRSA prevalence in south-west Spain and the highest MRSA prevalence in the central regions. Almost five-fold differences in MRSA proportions were seen between regions (range 10.3-54.5%). Compared with bloodstream infections, infections in other sites were more likely to be caused by MRSA (adjusted odds ratios for surgical site, urinary tract, skin and respiratory infections of 1.2, 1.2, 1.5 and 2.1, respectively).

[Application of European Model of Quality in Oncology]

OBJECTIVES

To assess a Medical Oncology Service using a healthcare setting version of the European Foundation for Quality Management (EFQM). To use this tool as training, an opportunity for participation and the base for checking the strategic planning.

MATERIAL AND METHODS

We use the EFQM Model adapted to healthcare centers EFQM as the evaluation instrument. It maintains scores and weights, only modifying vocabulary and simplifying that not relevant to the healthcare setting. Exercise was done with the "proform" system. Its advantage is that it uses standard formulas combined with open areas for discussion and presentation of ideas. It uses group sessions for agreement.

STUDY PERIOD

2001 Management. Evaluation was performed in the second term of 2002.

RESULTS

58 strengths and 37 areas of improvement were identified. These elements were used to create a strategic document, which served as the basis for future improvement. The score reached was used as an internal reference to monitor service quality evolution.

CONCLUSIONS

The EFQM model is applicable in a Medical Oncology Service, although it would be desirable to have standardized quality indicators that permit a more objective and specific evaluation.

[Quality of life following cataract surgery]

OBJECTIVE

To evaluate quality of life improvement after cataract surgery.

METHODS

Measurement of quality of life in 60-80-year-old patients undergoing phacoemulsification, both genders and able to comprehend the SF-36 quality of life questionnaire. The SF-36 explores the differences in quality of life before and after surgery. The questionnaire was completed prior to cataract surgery and six months after.

RESULTS

The answers of 75 patients were evaluated in this study. The average age was 73.88 S.E. 5.27 years old. After the surgery physical function increased (p=0.001), as did role limitation due to physical problems (p=0.007) and social function (p=0.003). Body pain, role limitation due to emotional problems, vitality, energy or tiredness, general health perception and health improved after surgery compared to one month before, but these findings were not statistically significant.

CONCLUSIONS

Quality of life can be measurably improved by cataract surgery. Disease-specific questionnaires, such as the SF-36, should be used whenever possible as an outcome measure in clinical practice. The phacoemulsification cataract surgery has proved to be effective in improving quality of life.

A new alcohol solution (N-duopropenide) for hygienic (or routine) hand disinfection is more useful than classic handwashing: in vitro and in vivo studies in burn and other intensive care units

INTRODUCTION

Standard handwashing is a key measure for the prevention of crossed nosocomial infection, but this measure is not always observed. We study whether fast disinfection with an alcohol solution is better than handwashing and whether it can enhance observance.

MATERIALS AND METHODS

The effects of several alcohol solutions on native and acquired microbiota are compared with classic handwashing in 'in vitro' and 'in vivo' (health volunteers) quantitative tests. A field assay was subsequently performed in severely ill patient intensive care units (ICUs) (Burn and other ICUs), using a semiquantitative method to compare the effects of disinfection with standard handwashing (n=102) with N-duopropenide alcohol application (n=264).

RESULTS AND DISCUSSION

In both designs--health volunteers and hospital ward teams--we found significant differences between handwashing and N-duopropenide application. Handwashing barely modified the native or acquired microbiota (only 0.1 to <2 log10 reduction) and did not eliminate Staphylococcus aureus and Gram-negative bacteria (from 34 to 23%: P>0.05). However, N-duopropenide reduced the acquired microbiota by 5 log (10) and the native hand microbiota by more than 2 log10, as well as significantly reducing S. aureus and Gram-negative bacteria (33-1.3%; P<0.01).

[Design, implementation, and results of the clinical pathway for herniated lumbar disk]

INTRODUCTION

Clinical or critical pathways are a useful tool in the continuous quality improvement. They develop the main characteristics of the quality programs: implementation of the evidence based medicine, increase staff and patient satisfaction and adequacy in hospital costs. This is the application of evidence-based medicine to a process management and it promotes integration of clinical guides, protocols and algorithms.

OBJECTIVE

We present our experience in the design, and first nine month's implementation and development of a clinical pathway for lumbar hemilaminectomy.

PATIENTS AND METHODS

This clinical pathway consists on four documents: main guide and check sheet, preprinted treatment orders and variation sheet, iconographic information for the patients and patient satisfaction questionnaire. After desing, development and a pilot study, the hemilaminectomy critical pathway was permanently adopted by our Service. A total of 106 patients underwent programmed lumbar disc hemilaminectomy in our Service between April and December-1999. Patients' average age was 44.7 years (SD = 11.2), 55.3% were men and 43.7% women. Twelve were hospitalized in a ward other than Neurosurgery unit and therefore were excluded from the study. This evaluation is based on the initial results obtained from both the pathway documents and the general data collected as usual during hospital care. The impact of the critical pathway on hospital stay has been assessed by comparing the average stay of critical pathway patients to the average of the 70 hemilaminectomies performed at our Service in the period April-December 1998.

RESULTS

Clinical pathway coverage has been 68% (standard > 80%). The patients' average stay was 4 days (SD = 1.1), one day more than planned. The pathway establishes a 4 day hospital stay (3 bed-days), a time that was fulfilled by 49% of the patients. The average stay of the 1998 patients was 5.6 days (SD = 2.7), 1.6 days more than the clinical pathway patients (p < 0.0001). Additionally, undesirable variability in the length of hospital stays was also reduced. Analysis of variations identified those corresponding to patient's condition, increases in medication beyond that originally specified due to patient needs, and unjustified prolonged stays. There were no systematic variations. There was a 2.2% incidence of adverse effects. Although satisfaction questionnaire was only returned by 51% of the patients (instead of > 70%), satisfaction index were 93% (vs 90%).

CONCLUSIONS

Critical pathways are still under development and changing continuously. Nevertheless their impact on improving patient care and satisfaction, and resource consumption is already evident, and it constitutes a major aim to work in its complete development.

Risk factors for surgical-wound infection in general surgery: a prospective study

OBJECTIVE

To quantify surgical-infection rate, to assess adherence with the antibiotic prophylaxis protocol, and to identify independent factors associated with surgical-wound infection (SWI).

METHODS

We carried out a prospective study of a cohort of 2,237 general surgery patients with postsurgery stays of more than 48 hours. Odds ratios (OR) were estimated using unconditional multiple logistic regression.

SETTING

A 1,300-bed, university-affiliated, tertiary-care hospital in Madrid, Spain.

RESULTS

254 patients developed SWI. The rate of adherence to the antibiotic prophylaxis protocol was 63.5%. Eight factors were independently associated with risk of SWI: age (OR = 1.2 for every 10 years of age); wound classification (clean-contaminated, OR = 6.4; contaminated, OR = 3.7; dirty or infected, OR = 9.3); antimicrobial prophylaxis (OR = 0.5); stay prior to surgery (OR = 1.1 for every 3 days); duration of operation (OR = 1.5 for every 60 minutes); malignant neoplasm (OR = 1.7); emergency procedure (OR = 1.99); intensive-care unit stay prior to surgery (OR = 2.6); and antimicrobial prophylaxis administered 2 or more hours before operation (OR = 5.3).

CONCLUSION

In general, antimicrobial prophylaxis protects against SWI (OR = 0.5); however, administration 2 hours or more before the operation increases the risk of SWI by a factor of 5.3. Therefore, measures should be taken to ensure the correct timing of antimicrobial prophylaxis.

Nosocomial infections in Spain: results of five nationwide serial prevalence surveys (EPINE Project, 1990 to 1994). Nosocomial Infections Prevalence Study in Spain

OBJECTIVE

To determine trends in rates of nosocomial infections in Spanish hospitals.

DESIGN

Prospective prevalence studies, performed yearly from 1990 through 1994.

SETTING

A convenience sample of acute-care Spanish hospitals.

PARTICIPANTS AND PATIENTS

The number of hospitals and patients included were as follows: 1990, 125 hospitals and 38,489 patients; 1991, 136 and 42,185; 1992, 163 and 44,343; 1993, 171 and 46,983; 1994, 186 and 49,689. A core sample of 74 hospitals, which participated in all five surveys and included a mean of 23,871 patients per year, was analyzed separately.

RESULTS

The overall prevalence rate of patients with nosocomial infections in the five studies was as follows: 1990, 8.5%; 1991, 7.8%; 1992, 7.3%; 1993, 7.1%; and 1994, 7.2%. The prevalence rate of patients with nosocomial infection in the core sample of 74 hospitals was 8.9%, 8.0%, 7.4%, 7.6%, and 7.6%, respectively (test for trend, P = .0001). Patients admitted to intensive-care units had a 22.8% prevalence rate of nosocomial infection in 1994. The most common nosocomial infections by primary site were urinary tract infection and surgical site infections, followed by respiratory tract infections and bacteremia. More than 60% of all infections were supported by a microbiological diagnosis.

CONCLUSIONS

The EPINE project provides a uniform tool for performing limited surveillance of nosocomial infections in most Spanish acute-care hospitals. Its use helps to spread an accepted set of definitions and methods for nosocomial infection control in the Spanish healthcare system. The surveys indicated that the prevalence of nosocomial infections has been reduced over the last 5 years in a core sample of Spanish hospitals.