Improving the culture of safety among healthcare workers: Integration of different instruments to gain major insights and drive effective changes

The Safety Attitude Questionnaire (SAQ) and Manchester Patient Safety Framework (MaPSaF) are known as effective tools to assess patient safety culture and climate and develop targeted strategies. However, they are seldom applied in an integrated way. The aim of this study was to conduct an implementation project through a novel use of both instruments to gain unique insights. The Italian version of MaPSaF and SAQ were administered to 1,759 healthcare workers from three Italian hospitals (response rate: MaPSaF 70.5%, SAQ 61.6%). MaPSaF evaluation proved an overall bureaucratic level of patient safety culture. SAQ scores showed a predominance of neutral scores (75.99%). The dimension perception of management gained the lowest mean score (53.32), while Stress recognition obtained the highest (75.17). Safety climate perception differed significantly among groups: working in a small hospital, in a medical department, and being a physician were associated with the most positive results. The majority (67.1%) of responders to both MaPSaF and SAQ considered the two instruments as providing with different and complementary information. Overall, results showed that an integrated approach in the evaluation of an organisation's safety culture may result useful for an in-depth analysis of the criticalities and the adoption of appropriate improvement strategies.

Outbreak of Saprochaete clavata Sepsis in Hematology Patients: Combined Use of MALDI-TOF and Sequencing Strategy to Identify and Correlate the Episodes

Introduction

New fungal species are increasingly reported in immunocompromised patients. Saprochaete clavata (S. clavata), an ascomycetous fungus formerly called Geotrichum clavatum, is intrinsically resistant to echinocandins and is often misidentified.

Objective

We describe a cluster of seven S. clavata infections in hospitalized hematology patients who developed this rare fungemia within a span of 11 months. Three of the seven patients died. Identification of the isolates was determined only with the Saramis database of VitekMS system and sequencing of the internal transcribed spacer (ITS) region. Clonal relatedness of the isolates was determined by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF) analysis; clonal correlation between the strains was investigated by means of phylogenetic analysis, based on single-nucleotide variants (SNPs). Clinical presentation, 1–3 β-D-glucan (BG) and galactomannan (GM) antigen results and analysis of possible sources of contamination are also described with a prospective case–control study of the outbreak.

Results

MALDI-TOF MS-Vitek (bioMerieux, Marcy l’Etoile, France) failed to identify the six isolates, while SARAMIS (bioMerieux, Marcy l’Etoile, France) identified the isolates as S. clavata. Initially, Vitek 2 identified the strains as Geotrichum capitatum in two of the seven cases. Molecular identification gave 99% homology with S. clavata. BG was positive in three out of six patients (range 159 to >523 pg/ml), GM results were always negative. All the isolates were resistant to echinocandins (anidulafungin, micafungin, and caspofungin) and Fluconazole, but susceptible to Flucytosine and Voriconazole. One isolate showed acquired resistance to Flucytosine and Amphotericin B during treatment. Both the correlation-based dendrograms obtained by MALDI-TOF MS (Bruker Daltonics) and MS-Vitek not only clustered six of the seven bloodstream infection (BSI) isolates in the same group, but also showed their strong relatedness. Phylogenetic analysis using SNPrelate showed that the seven samples recorded during the investigation period clustered together. We observed a split between one case and the remainder with a node supported by a z-score of 2.3 (p-value = 0.021) and 16 mutations unique to each branch.

Conclusion

The use of proteomics for identification and evaluation of strain clonality in outbreaks of rare pathogens is a promising alternative to laborious and time-consuming molecular methods, even if molecular whole-genome sequencing (WGS) typing will still remain the reference method for rare emergent pathogens.

"Should I stay or Should I go": patient who leave Emergency Department of an Italian Third-Level Teaching Hospital

Background and Aim: Patients could leave ED not receiving the desired care either Without Being Seen by a doctor (LWBS) or Against Medical Advice (DAMA). In term of care quality, LWBS may be related to inappropriate access and process of care, while DAMA may lead to increased risk of mortality and re-admissions. This study aims to identify frequency of patients who leave ED, determine their characteristics and identify associated factor. Methods: This was a retrospective observational study of patients that attended EDs of University Hospital Trust of Verona in 2017. Demographic and ED access associated variables were collected for LWBS, DAMA and completed-ED-treatment patients. Univariate and multivariate data analyses was based on EMUR-PS administrative data.Results: 5,901 of 127,180 ED accesses were uncompleted treatment (4.64%); LWBS were 4,664 (79.04%) and DAMA 1,237 (20.96%). Those who leave ED tended to be younger (39.35 vs. 45.56, p<0.01). Independent factors associated with ED leaving resulted: i) non-urgent triage category (OR: 2.941, 95%CI: 2.405-3.596) ii) non-Italian-nationality (OR: 1.695, 95%CI: 1.493-1.924) and requiring psychiatric consult (OR:6.16 95%IC 4.82-7.87); while protective factors resulted: i) female gender (OR: 0.713, 95%CI: 0.633-0.803); i) Paediatric ED (OR: 0.593, 95%CI: 0.437-0.805); ii) Obstetrics-Gynaecology ED (OR: 0.284, 95%CI: 0.193-0.416) iii) inclusion in fast track pathways (OR: 0.747, 95%CI: 0.602-0.927). Higher ED leaving rate were observed during night-time and Sunday, either overcrowding resulted not associated.Conclusion: Results show the necessity to implement primary care-ED integrated pathway, mainly in frail sub-population, improve awareness on healthcare service use and refine communication skills in ED-team. (www.actabiomedica.it)