[Unfractionned heparin wastage at a French university hospital]

OBJECTIVES

In a context of heparin shortage, we studied the wasted quantities in three intensive care units (ICU) of a university hospital where two electric syringe pump (ESP) heparin protocols coexist (20,000UI/48mL used in the cardiology ICU and 25,000UI/50mL use in the medical and surgical ICUs).

METHOD

We performed a prospective observational study of patients treated with heparin ESP. We collected the information recorded in the prescription software connected to the ESP (dosage, start time, infusion rate, interruption times, date and time of end of treatment). We observed the ESPs, noted the time of start written on the label and the quantity remaining, and questioned nurses about the constraints that lead for changing the ESPs.

RESULTS

Between 23/03/23 and 19/05/23, 164 vials of 25,000UI/5mL were used. The wasted quantity was equivalent 42 vials: 18 vials (43%) of treatment stopped, nurses practices such as changing the ESP in advance 6 vials (14%), application of the rule "discard the ESP 24hours after preparation" 9 vials (21.5%) and 9 vials (21.5%) corresponding to the 45mL discarded for the 45 ESP prepared in the cardiology ICU.

CONCLUSION

More than a quarter of the heparin purchased is wasted. The results should lead to policy decisions concerning the medications supply chain, i.e. abandoning the 20,000UI/48mL protocol, supply of ready to use heparin syringes by industry or by the pharmacy. It is essential that these data be fed back to nurses' teams, in order to gather their suggestions before considering any changes of their practices.

[Analysis of heparin sodium prescribing practices with a electric syringe pump]

OBJECTIVES

Report on the practices of prescribing continuous infusion of heparin sodium by syringe pump in our hospital and shed qualitative light on the protocols used in other French hospitals.

METHODS

We interviewed prescribers about the protocol they were using through the computerized provider order entry system. At the same time, we asked hospital pharmacists, particularly through a social network, whether in their hospital one or more protocols were used and which ones.

RESULTS

81 prescribers responded to our request: 22 indicated prescribing the 25000IU/50mL protocol, 7 the 20000IU/48mL protocol, 2 the 25000IU/48mL protocol and 14 indicated that they had no preference for one of them. Ten responded that they did not prescribe any protocols and 26 left the question unanswered. The responses of 42 pharmacists practicing in other establishments allowed us to identify 16 different protocols. Of these 42 establishments, 10 had at least two protocols.

CONCLUSIONS

Several protocols for the administration by continuous infusion of heparin sodium with a syringe pump can coexist within a hospital. This diversity is confusing and puts patients and caregivers at risk of medication errors. Among all these protocols, it is not known whether some are riskier than others and research to clarify this unknown is warranted. Defining a national standard concentration of heparin and bringing to the market ready-to-administer solutions are measures to be promoted in order to reduce the risk of errors.

[Do initial experience with an enhanced recovery program after surgery (ERAS) improve postoperative outcomes after cystectomy?]

OBJECTIVE

To estimate the feasibility and the impact of an ERAS program after radical cystectomy for bladder cancer.

MATERIALS AND METHODS

This was a retrospective study comparing a historical pre ERAS group, including all the patients undergoing cystectomy for bladder cancer from January 2013 to December 2015 with a classic procedure, and an interventional ERAS group after introducing an enhanced recovery protocol before, during and after surgery, from February 2016. The principal outcome was the postoperative length of stay. Secondary outcomes mesures were impact on perioperative complication rate (Clavien classification≥3B), readmission rate, reanimation length of stay, ileus rate and adherence to the ERAS protocol.

RESULTS

There were no differences between the 2 groups as far as demographics characteristics are concerned. In total, 97 patients were included, 56 in the control group, and 41 in the ERAS group. The adherence to the protocol was about 65.8%. The ERAS group had statistically significantly shorter median length of stay (D19 versus D14; P: 0.021). The major complications rate (Clavien≥3B) were about 23.2% for the control group and 12.1% for the ERAS group (P: NS). The reinsertion of nasogastric tube were higher in the control group (39.3% vs 21.9%; P: NS) and the readmission rate was about 7.1% in the control group versus 14.6% in the ERAS group (P: NS).

CONCLUSION

In conclusion, introduction and application of an enhanced recovery protocol (ERAS) after cystectomy for bladder cancer allowed for better management of postoperative outcomes. It is clearly feasible in cystectomy, and improve significantly the median postoperative length of stay. Moreover, it may be effective in terms of faster return of bowel function and reduction of majors complications.

LEVEL OF EVIDENCE

4.

[Spotting the GLObalRIsk of severe outcomes in undiagnosed COPD patients (GLORI-COPD)]

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a severe chronic disease and its prevalence is increasing. Nevertheless, mortality linked to moderate and mild COPD without comorbidities is low. The aim of the study is to create and validate a questionnaire in primary care to spot patients with undiagnosed COPD who are at high risk of severe complications considering the severity of their COPD and their comorbidities.

METHODS

The development of the questionnaire has three steps. The first is the selection of the items which can be included in the questionnaire with a two-round Delphi method. The second step is a cross-sectional study to assess the link between spirometry and the selected items in the first step. The last step is the validation of the questionnaire in a prospective study in primary care.

EXPECTED RESULTS

Identifying undiagnosed COPD patients with a high global risk of complications in primary care will help to establish which patients have to be diagnosed as a priority. This is particularly useful in general practice as the patient is considered globally and not just on the basis of respiratory criteria. It should allow better selection of patients who need specialised follow up.

[Neuropathology of sudden infant death syndrome: Review of the literature and proposal of a protocol for neuropathological examination]

According to the French High Authority for Health, sudden unexpected death in infants (SUDI) is defined as "a sudden death that occurs in an infant, whereas nothing in its known history could have predicted it". This is an exclusion diagnosis. There are great interregional disparities despite the professional recommendations established in February 2007. For the examination of the brain, instructions are not adapted to current and research practice. The role of the pathologist, like anyone involved in SUDI, is to eliminate an abuse head trauma and to determine the cause of death. Major neuropathological lesions by definition do not exist. Lesions of hypoxia/ischemia are the most frequent but not specific. The accessibility of anti-APP immunoblotting has highlighted the role of anoxia in the development of axonal diffuse damages. Many studies are looking for a neurological substratum of the SUDI (neuropathological and/or neurobiochinic). This article aims to define a detailed sampling protocol based on foreign consensus and current data of science in order to assist pathologists and to promote a homogeneous data bank in France.

[Study of the reproducibility of the sterilization process and proposal of an sterilizer requalification protocol]

Unlike EN 554, and since the publication of ISO 17665-1 standard, the user of autoclaves may use methods other than those indicated in the guidelines. Outsourcing the requalification of sterilizers by an external service provider and after observing from the previous requalification reports that the thermometric data seemed reproducible, we decided to propose and validate a validation method for the reproducibility of the sterilization process. This is to exempt from the study of the repeatability of the EN 554 standard in future requalifications. Reproducibility was studied with the sensors of the sterilization service and from the production cycles. This study was carried out in three parts. First, we checked whether our sensors were reliable. Then we evaluated the sterilization process fidelity of each sterilizer. Finally, we compared our measurements performed by the service sensors with the measurements performed by the service provider during the requalifications of the previous years. This work leads us to describe a new protocol of requalification of our sterilizers.

[Vaginal delivery in case of breech presentation: Impact of a service's incentive]

OBJECTIVES

The mode of delivery in podalic presentation was controvertible since the 2000s, which led to a high rate of caesarean section. In our center, the delivery mode was physician-dependent before 2012. Since 2012, the management of podalic presentations was supervised by a protocol allowing a collegiate management to promote vaginal delivery. The objective of this study was to evaluate the impact of this policy on neonatal outcomes and obstetric practices.

METHODS

A retrospective study was carried out with comparison of 135 patients who gave birth in 2008 with 110 patients who gave birth in 2014, before and after the implementation of the protocol in a type III university maternity hospital. Two hundred and forty-five singleton pregnancies with podalic presentation and a gestational age more than 32 weeks of gestation were included in this study. The rate of vaginal delivery trial, the evolution of clinical practices and neonatal outcomes were respectively compared.

RESULTS

One hundred and twenty-six patients who gave birth in 2008 were compared to the 105 one of 2014. The rate of successful vaginal birth trial increased from 32.7% (n=16/49) to 63.8% (n=37/58) (P>0.05) between the two periods, this induced a decrease of 16.3% of planned caesarean sections rate [(77/126) versus (47/105) (P<0.02)] and of 6.2% of emergency caesarean sections rate [(33/126) versus (21/105) (P<0.001)]. No significant difference was observed regarding neonatal outcomes.

CONCLUSIONS

This work shows that it is possible to limit the rate of planned and emergency caesarean sections because of an incentive policy of service without impact on neonatal morbidity and mortality.

[Shoulder dystocia: Quality of retranscription in medical files]

OBJECTIVE

Shoulder dystocia is a rare obstetrical event and potentially serious. Apart from possible psychological implications, it may be responsible for maternal (haemorrhage and perineal tear) and neonatal complications (brachial plexus) leading to complaints and even lawsuits. The transcription of this event in medical files is essential as it is a reflection of the work in an emergency. It allows the obstetrician to defend him in case of trial. Our objective was to assess the quality of the transcription of shoulder dystocia situations in medical files.

METHOD

Retrospective chart study conducted in a university hospital with maternity type III. The primary objective was the rate of comprehensive records (name maneuvers and order of maneuvers of the anterior shoulder hand, time between the expulsion of the head and body, Apgar score).

RESULTS

Between 2007 and 2015, 54 cases of shoulder dystocia requiring a second line maneuver after vaginal delivery (Wood and/or Jacquemier) were included. In all, 98.2% of the files were incomplete. The maneuvers and their order were noted in 100% of cases. However, the operation was not correctly described in 16.7% of cases. The anterior shoulder was noted in 16.7% of cases. The time between the expulsion of the head and the body was noted in one single files. Neither broken collarbone nor brachial plexus were observed.

CONCLUSION

To improve the management of dystocia shoulder and transcription of data in files, simulation sessions and the creation of a standardized form would be needed.

[Multicenter survey on ventilator-associated pneumonia prevention in intensive care]

OBJECTIVE

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in intensive care unit (ICU). The aim of the study was to evaluate the follow-up of the guidelines for VAP prevention.

STUDY DESIGN

Retrospective, observational and multicenter study.

PATIENTS AND METHODS

During one year, all patients with mechanical ventilation over 48 hours were included in the CCLIN-Ouest Network. The demographic characteristics of the patients, the use of specific protocol for VAP prevention and the density of incidence of VAP were recorded. The use of a protocol for preventing VAP (absence, incomplete, complete and care bundle (i.e. complete prevention of VAP with weaning mechanical protocol and sedation protocol)) was collected.

RESULTS

26 ICU with 5742 patients were included. Ten ICU (38%; 2595 patients) had no protocol for VAP prevention, eight ICU (31%; 1821 patients) had an incomplete protocol, five ICU (19%; 561 patients) had a complete protocol and three ICU (12%; 765 patients) had a care bundle. The density of incidence of VAP was 14.8‰ (Interquartile range [IQR]: 10.2-0.1) for no protocol group, 15.6‰ [IQR: 12.6-6.2] for incomplete protocol group, 11.0‰ [IQR: 9.1-14.0] for complete protocol group and 12.9‰ [5-7,7-9,9-12] for care bundle group (P=0.742).

CONCLUSIONS

The compliance to prevention of VAP was poor. Proposals for improving practice are discussed.